Pediatric Dentistry

Pediatric dentistry (formerly Pedodontics/Paedodontics) primarily focuses on children from birth through adolescence. 

One of the most important components of pediatric dentistry is child psychology.  Pediatric dentists are trained to create a friendly, fun, social atmosphere for visiting children, and always avoid threatening words like “drill,” “needle,” and “injection.”  Dental phobias beginning in childhood often continue into adulthood, so it is of paramount importance that children have positive experiences and find their “dental home” as early as possible.

What Does a Pediatric Dentist Do?

Dentists fulfill many important functions pertaining to the child’s overall oral health and hygiene.  They place particular emphasis on the proper maintenance and care of deciduous (baby) teeth, which are instrumental in facilitating good chewing habits, proper speech production, and also hold space for permanent teeth.

Other important functions include:

Education – Dentists educate the child using models, computer technology, and child-friendly terminology; thus emphasizing the importance of keeping teeth strong and healthy.  In addition, they advise parents on disease prevention, trauma prevention, good eating habits, and other aspects of the home hygiene routine.

Monitoring growth – By continuously tracking growth and development, dentists are able to anticipate dental issues and quickly intervene before they worsen.  Also, working towards earlier corrective treatment preserves the child’s self-esteem and fosters a more positive self-image.

Prevention – Helping parents and children establish sound eating and oral care habits reduces the chances of later tooth decay.  In addition to providing check ups and dental cleanings, pediatric dentists are also able to apply dental sealants and topical fluoride to young teeth, advise parents on thumb- sucking/pacifier/smoking cessation, and provide good demonstrations of brushing and flossing.

Intervention – In some cases, dentists may discuss the possibility of early oral treatments with parents.  In the case of oral injury, malocclusion (bad bite), or bruxism (grinding), space maintainers may be fitted, a nighttime mouth guard may be recommended, or reconstructive surgery may be scheduled.

First Visit

According to AAPD (American Academy of Pediatric Dentistry) guidelines, infants should initially visit the pediatric dentist around the time of their first birthday.  First visits can be stressful for parents, especially for parents who have dental phobias themselves.

It is imperative for parents to continually communicate positive messages about dental visits (especially the first one), and to help the child feel as happy as possible about visiting the dentist.

How can I prepare for my child’s first dental visit?

There are several things parents can do to make the first visit enjoyable.  Some helpful tips are listed below:

Take another adult along for the visit – Sometimes infants become fussy when having their mouths examined.  Having another adult along to soothe the infant allows the parent to ask questions and to attend to any advice the dentist may have.

Avoid threatening language –  Dentists and staff are trained to avoid the use of threatening language, like drills, needles, injections, and bleeding.  It is imperative for parents to use positive language when speaking about dental treatment with their child.

Provide positive explanations – It is important to explain the purposes of the dental visit in a positive way.  Explaining that the dentist “helps to keep teeth healthy” is far better than explaining that the dentist “is checking for tooth decay, and may have to drill the tooth if decay is found.”

Explain what will happen – Anxiety can be vastly reduced if the child knows what to expect.  Age-appropriate books about visiting the dentist can be very helpful in making the visit seem fun. Here is a list of parent and dentist-approved books:

• The Berenstain Bears Visit the Dentist – by Stan and Jan Berenstain.
• Show Me Your Smile: A Visit to the Dentist – Part of the “Dora the Explorer” Series.
• Going to the Dentist – by Anne Civardi.
• Elmo Visits the Dentist – Part of the “Sesame Street” Series.

What will happen during the first visit?

There are several goals for the first dental visit.  First, the dentist and the child need to get properly acquainted.  Second, the dentist needs to monitor tooth and jaw development to get an idea of the child’s overall health history.  Third, the dentist needs to evaluate the health of the existing teeth and gums.  Finally, the dentist aims to answer questions and advise parents on how to implement a good oral care regimen.

The following sequence of events is typical of an initial “well baby checkup”:

1. Dental staff will greet the child and parents.
2. The infant/family health history will be reviewed (this may include questionnaires).
3. The dentist will address parental questions and concerns.
4. More questions will be asked, generally pertaining to the child’s oral habits, pacifier use, general development, tooth alignment, tooth development, and diet.
5. The dentist will provide advice on good oral care, how to prevent oral injury, fluoride intake, and sippy cup use.
6. The infant’s teeth will be examined. Generally, the dentist and parent sit facing each other.  The infant is positioned so that his or her head is cradled in the dentist’s lap.  This position allows the infant to look at the parent during the examination.
7. Good brushing and flossing demonstrations will be provided.
8. The state of the child’s oral health will be described in detail, and specific recommendations will be made.  Recommendations usually relate to oral habits, appropriate toothpastes and toothbrushes for the child, orthodontically correct pacifiers, and diet.
9. The dentist will detail which teeth may appear in the following months.
10. The dentist will outline an appointment schedule and describe what will happen during the next appointment.

Dental Radiographs (X-Rays)

Dental radiographs, also known as dental X-rays, are important diagnostic tools in pediatric dentistry.  Dental radiographs allow the dentist to see and treat problems like childhood cavities, tooth decay, orthodontic misalignment, bone injuries, and bone diseases before they worsen.  These issues would be difficult (in some cases impossible) to see with the naked eye during a clinical examination.

The American Academy of Pediatric Dentistry (AAPD) approves the use of dental radiographs for diagnostic purposes in children and teenagers.  Although radiographs only emit tiny amounts of radiation and are safe to use on an occasional basis, the AAPD guidelines aim to protect young people from unnecessary X-ray exposure.

What are dental X-rays used for?

Dental x-rays are extremely versatile diagnostic tools.  Some of their main uses in pediatric dentistry include:

• Assessing the amount of space available for incoming teeth.
• Checking whether primary teeth are being shed in good time for adult teeth to emerge.
• Evaluating the progression of bone disease.
• Monitoring and diagnosing tooth decay.
• Planning treatment (especially orthodontic treatment).
• Revealing bone injuries, abscesses, and tumors.
• Revealing impacted wisdom teeth.

When will my child need dental X-rays?

Individual circumstances dictate how often a child needs to have dental radiographs taken.  Children at higher-than-average risk of childhood tooth decay (as determined by the dentist) may need biannual radiographs to monitor changes in the condition of the teeth.  Likewise, children who are at high risk for orthodontic problems, for example, malocclusion, may also need sets of radiographs taken more frequently for monitoring purposes.

Children at average or below average risk for tooth decay and orthodontic problems should have a set of dental X-rays taken every one to two years.  Even in cases where the dentist suspects no decay at all, it is still important to periodically monitor tooth and jaw growth – primarily to ensure there is sufficient space available for incoming permanent teeth.

If the oral region has been subject to trauma or injury, the dentist may want to X-ray the mouth immediately.  Developments in X-ray technology mean that specific areas of the mouth can be targeted and X-rayed separately, reducing the amount of unnecessary X-ray exposure.

What precautions will be taken to ensure my child’s safety?

Though dental radiographs are perfectly safe for use on children, the dentist will take several precautions to ensure the X-ray process does not unduly damage the child’s cells and bodily tissues.

First, the child will be covered in a lead apron to protect the body from unnecessary exposure.  Second, the dentist will use shields to protect the parts of the face that are not being X-rayed.  Finally, the dentist will use high-speed film to reduce radiation exposure as much as possible.

Dental Emergencies

Although dental injuries and dental emergencies are often distressing for both children and parents, they are also extremely common.  Approximately one third of children have experienced some type of dental trauma, and more have experienced a dental emergency.

There are two peak risk periods for dental trauma – the first being toddlerhood (18-40 months) when environmental exploration begins, and the second being the preadolescent/adolescent period, when sporting injuries become commonplace.

Detailed below are some of the most common childhood dental emergencies, in addition to helpful advice on how to deal with them.

Toothache

Toothache is common in children of all ages and rarely occurs without cause.  Impacted food can cause discomfort in young children, and can be dislodged using a toothbrush, a clean finger, or dental floss.  If pain persists, contact the pediatric dentist.  Some common causes of toothache include: tooth fractures, tooth decay, tooth trauma, and wisdom teeth eruption (adolescence).

How you can help:

1. Cleanse the area using warm water.  Do not medicate or warm the affected tooth or adjacent gum area.
2. Check for impacted food and remove it as necessary.
3. Apply a cold compress to the affected area to reduce swelling.
4. Contact the dentist to seek advice.

Dental avulsion (knocked-out tooth)

If a tooth has been knocked-out of the child’s mouth completely, it is important to contact the dentist immediately.  In general, dentists do not attempt to reimplant avulsed primary (baby) teeth, because the reimplantation procedure itself can cause damage to the tooth bud, and thereby damage the emerging permanent tooth.

Dentists always attempt to reimplant avulsed permanent teeth, unless the trauma has caused irreparable damage.  The reimplantation procedure is almost always more successful if it is performed within one hour of the avulsion, so time is of the essence!

How you can help:

1. Recover the tooth.  Do not touch the tooth roots! Handle the crown only.
2. Rinse off dirt and debris with water without scrubbing or scraping the tooth.
3. For older children, insert the tooth into its original socket using gentle pressure, or encourage the child to place the tooth in the cheek pouch.  For younger children, submerge the tooth in a glass of milk or saliva (do not attempt to reinsert the tooth in case the child swallows it).
4. Do not allow the tooth to dry during transportation.  Moisture is critically important for reimplantation success.
5. Visit the pediatric dentist (where possible) or take the child to the Emergency Room immediately –time is critical in saving the tooth.

Dental intrusion (tooth pushed into jawbone)

Sometimes, dental trauma forces a tooth (or several teeth) upwards into the jawbone.  The prognosis is better for teeth that have been pushed up to a lesser extent (less than 3mm), but every situation is unique.  Oftentimes, the force of the trauma is great enough to injure the tooth’s ligament and fracture its socket.

If dental intrusion of either the primary or permanent teeth is suspected, it is important to contact the dentist immediately.  Depending on the nature and depth of the intrusion, the dentist will either wait for the tooth to descend naturally, or perform root canal therapy to preserve the structure of the tooth.

How you can help:

1. Rinse the child’s mouth with cold water.
2. Place ice packs around affected areas to reduce swelling.
3. Offer Tylenol for pain relief.
4. Contact the dentist where possible, or proceed to the Emergency Room.

Tooth luxation/extrusion/lateral displacement (tooth displacement)

Tooth displacement is generally classified as “luxation,” “extrusion,” or “lateral displacement,” depending on the orientation of the tooth following trauma.  A luxated tooth remains in the socket – with the pulp intact about half of the time.  However, the tooth protrudes at an unnatural angle and the underlying jawbone is oftentimes fractured.

The term “extrusion” refers to a tooth that has become partly removed from its socket.  In young children, primary tooth extrusions tend to heal themselves without medical treatment.  However, dental treatment should be sought for permanent teeth that have been displaced in any manner in order to save the tooth and prevent infection.  It is important to contact the dentist if displacement is suspected.

How you can help:

1. Place a cold, moist compress on the affected area.
2. Offer pain relief (for example, Children’s Tylenol).
3. Contact the dentist immediately.

Crown fracture

The crown is the largest, most visible part of the tooth.  In most cases, the crown is the part of the tooth that sustains trauma.  There are several classifications of crown fracture, ranging from minor enamel cracks (not an emergency) to pulp exposure (requiring immediate treatment).

The dentist can readily assess the severity of the fracture using dental X-rays, but any change in tooth color (for example, pinkish or yellowish tinges inside the tooth) is an emergency warning sign.  Minor crown fractures often warrant the application of dental sealant, whereas more severe crown fractures sometimes require pulp treatments.  In the case of crown fracture, the dentist should be contacted. Jagged enamel can irritate and inflame soft oral tissues, causing infection.

How you can help:

1. Rinse the child’s mouth with warm water.
2. Place a cold, moist compress on the affected area.
3. Offer strong pain relief (for example, Children’s Tylenol).
4. Pack the tooth with a biocompatible material.
5. Visit the dentist or Emergency Room depending on availability and the severity of the injury.

Root fracture

A root fracture is caused by direct trauma, and isn’t noticeable to the naked eye.  If a root fracture is suspected, dental x-rays need to be taken.  Depending on the exact positioning of the fracture and the child’s level of discomfort, the tooth can be monitored, treated, or extracted as a worse case scenario.

How you can help:

1. Place a cold, moist compress on the affected area.
2. Offer pain relief (for example, Children’s Tylenol).
3. Contact the dentist.

Dental concussion

A tooth that has not been dislodged from its socket or fractured, but has received a bang or knock, can be described as “concussed.”  Typically occurring in toddlers, dental concussion can cause the tooth to discolor permanently or temporarily.  Unless the tooth turns black or dark (indicating that the tooth is dying and may require root canal therapy), dental concussion does not require emergency treatment.

Injured cheek, lip or tongue

If the child’s cheek, lip or tongue is bleeding due to an accidental cut or bite, apply firm direct pressure to the area using a clean cloth or gauze.  To reduce swelling, apply ice to the affected areas.  If the bleeding becomes uncontrollable, proceed to the Emergency Room or call a medical professional immediately.

Fractured jaw

If a broken or fractured jaw is suspected, proceed immediately to the Emergency Room.  In the meantime, encourage the child not to move the jaw.  In the case of a very young child, gently tie a scarf lengthways around the head and jaw to prevent movement.

Head injury/head trauma

If the child has received trauma to the head, proceed immediately to the Emergency Room.  Even if consciousness has not been lost, it is important for pediatric doctors to rule out delayed concussion and internal bleeding.

First Year or First Tooth

Dental Care is Crucial During the First Year of Life

Proper care for baby teeth is imperative as they serve several critical functions, including:

• Fostering good nutrition by permitting proper chewing Aiding speech development Helping proper development of permanent teeth by saving space for them
• The American Academy of Pediatric Dentistry (AAPD), American Dental Association (ADA) and the American Academy of Pediatrics all recommend a dental visit for children by age one.
• Baby teeth are vulnerable to tooth decay from their very first appearance, on average between the ages of six and 12 months.
• The associative pain of tooth decay can prevent a child from eating correctly, impacting overall health and development. Additionally, undetected and untreated tooth decay can lead to infection, loss of teeth and expensive and mostly preventable emergency and restorative interventions.
• A scientific paper in the journal Pediatric Dentistry revealed that children who wait to have their first dental visit until age two or three are more likely to require restorative and emergency visits.

Benefits of the Year One Dental Visit

• 1 + 1 = ZERO. ONE dental visit when there’s ONE tooth can equal ZERO cavities.
• Visiting a dentist by the time the first baby tooth appears enables the child to begin a lifelong preventive dental care program to minimize tooth decay and cavities.
• Dentists can detect early tooth decay, provide parents with information on proper oral and facial development, determine fluoride needs and more.
• The year one dental visit can actually save money. A study in the journal Pediatrics showed that children who have their first dental visit before age one have 40 percent lower dental costs in their first five years than children who do not, due to the cost of dental and medical procedures that may be necessary as a result of poor oral health.

Recommended At-home Dental Care During Year One

Even before baby teeth appear, infants need proper oral care and fluoride supplements to help developing teeth grow strong and avoid early childhood caries.

• Parents should clean infant mouths and gums regularly with a soft infant toothbrush or cloth and water.
• Children older than six months need fluoride supplements if their drinking water does not contain enough fluoride. Fluoride supplementation in infants has been shown to reduce tooth decay by as much as 50 percent.
• Infants and young children have other unique caries-risk factors including development of dietary habits and childhood food preferences. Breast-feeding at will should be avoided after the first primary tooth begins to erupt and other dietary carbohydrates are introduced.
• Parents should be encouraged to have infants drink from a cup as they approach their first birthday. Infants should be weaned from the bottle by 12-14 months of age.
• Baby teeth should be brushed at least twice a day with an aged-appropriate sized toothbrush using a “smear” of fluoridated toothpaste.

Care for Your Child’s Teeth

Pediatric oral care has two main components: preventative care at the pediatric dentist’s office and preventative care at home.  Though infant and toddler caries (cavities) and tooth decay have become increasingly prevalent in recent years, a good dental strategy will eradicate the risk of both.

The goal of preventative oral care is to evaluate and preserve the health of the child’s teeth.  Beginning at the age of twelve months, the American Dental Association (ADA) recommends that children begin to visit the pediatric dentist for “well baby” checkups.  In general, most children should continue to visit the dentist every six months, unless instructed otherwise.

How can a dentist care for my child’s teeth?

The dentist examines the teeth for signs of early decay, monitors orthodontic concerns, tracks jaw and tooth development, and provides a good resource for parents.  In addition, the dentist has several tools at hand to further reduce the child’s risk for dental problems, such as topical fluoride and dental sealants.

During a routine visit to the dentist, the child’s mouth will be fully examined, the teeth will be professionally cleaned, topical fluoride may be coated onto the teeth to protect tooth enamel, and any parental concerns can be addressed.  The dentist can demonstrate good brushing and flossing techniques, advise parents on dietary issues, provide strategies for thumb sucking and pacifier cessation, and communicate with the child on his or her level.

When molars emerge (usually between the ages of two and three), the dentist may coat them with dental sealant.  This sealant covers the hard-to-reach fissures on the molars, sealing out bacteria, food particles and acid.  Dental sealant may last for many months or many years, depending on the oral habits of the child. Dental sealant provides an important tool in the fight against tooth decay.

How can I help at home?

Though most parents primarily think of brushing and flossing when they hear the words “oral care,” good preventative care includes many more factors, such as:

Diet – Parents should provide children with a nourishing, well-balanced diet.  Very sugary diets should be modified and continuous snacking should be discouraged.  Oral bacteria ingest leftover sugar particles in the child’s mouth after each helping of food – emitting harmful acids that erode tooth enamel, gum tissue, and bone if left unchecked.  Space out snacks where possible, and provide the child with non-sugary alternatives like celery sticks, carrot sticks, and low-fat yogurt.

Oral habits – Though pacifier use and thumb sucking generally cease over time, both can cause the teeth to misalign.  If the child must use a pacifier, choose an “orthodontically” correct model.  This will minimize the risk of developmental problems like narrow roof arches and crowding.  The dentist can suggest a strategy (or provide a dental appliance) for thumb sucking cessation.

General oral hygiene – Sometimes, parents cleanse pacifiers and teething toys by sucking them.  Parents may also share eating utensils with the child.  Harmful oral bacteria are transmitted from parent-to-child in these ways, increasing the risk of early cavities and tooth decay.  Instead, rinse toys and pacifiers with warm water and avoid spoon-sharing wherever possible.

Sippy cup use – Sippy cups are an excellent transitional aid for the baby bottle-to-adult drinking glass period.  However, sippy cups filled with milk, breast milk, soda, juice, and sweetened water cause small amounts of sugary fluid to continually swill around young teeth – meaning continuous acid attacks on tooth enamel.  Sippy cup use should be terminated between the ages of twelve and fourteen months – or whenever the child has the motor capabilities to hold a drinking glass.

Brushing – Children’s teeth should be brushed a minimum of two times per day using a soft bristled brush and a pea-sized amount of toothpaste.  Parents should help with the brushing process until the child reaches the age of seven and is capable of reaching all areas of the mouth.  Parents should always opt for ADA approved toothpaste (non-fluoridated before the age of two, and fluoridated thereafter).  For babies, parents should rub the gum area with a clean cloth after each feeding.

Flossing – Cavities and tooth decay form more easily between teeth.  Therefore, the child is at risk for between-teeth cavities wherever two teeth grow adjacent to each other.  The dentist can help demonstrate correct head positioning during the flossing process, and suggest tips for making flossing more fun!

Fluoride – Fluoride helps prevent mineral loss and simultaneously promotes the remineralization of tooth enamel.  Too much fluoride can result in fluorosis, a condition where white specks appear on the permanent teeth, and too little can result in tooth decay.  It is important to get the fluoride balance correct.  The dentist can evaluate how much the child is currently receiving and prescribe supplements if necessary.

Baby Bottle Tooth Decay

Maintaining the health of primary (baby) teeth is exceptionally important.  Although baby teeth will eventually be replaced, they fulfill several crucial functions in the meantime.

Baby teeth aid enunciation and speech production, help the child to chew food correctly, maintain space in the jaw for adult teeth, and prevent the tongue from posturing abnormally in the mouth.  When baby teeth are lost prematurely due to decay or trauma, adjacent teeth shift to fill the gap.  This phenomenon can lead to impacted adult teeth, years of orthodontic treatment, and a poor aesthetic result.

Babies are at risk for tooth decay as soon as the first primary tooth emerges – usually around the age of six months.  For this reason, the American Academy of Pediatric Dentistry (AAPD) recommends a “well baby check up” with a dentist around the age of twelve months.

What is baby bottle tooth decay?

The term “baby bottle tooth decay” refers to early childhood caries (cavities), which occur in infants and toddlers.  Baby bottle tooth decay may affect any or all of the teeth, but is most prevalent in the front teeth on the upper jaw.

If baby bottle tooth decay becomes too severe, the dentist may be unable to save the affected tooth.  In such cases, the damaged tooth is removed, and a space maintainer is provided to prevent misalignment of the remaining teeth.

Scheduling regular checkups with a dentist and implementing a good homecare routine can completely prevent baby bottle tooth decay.

How does baby bottle tooth decay start?

Acid-producing bacteria in the oral cavity cause tooth decay.  Initially, these bacteria may be transmitted from mother or father to baby through saliva.  Every time parents share a spoon with the baby or attempt to cleanse a pacifier with their mouths, the parental bacteria invade the baby’s mouth.

The most prominent cause of baby bottle tooth decay however, is frequent exposure to sweetened liquids.  These liquids include breast milk, baby formula, juice, and sweetened water – almost any fluid a parent might fill a baby bottle with.

Especially when sweetened liquids are used as a naptime or nighttime drink, they remain in the mouth for an extended period of time.  Oral bacteria feed on the sugar on and around the teeth and then emit harmful acids. These acids attack tooth enamel and wear it away.  The result is painful cavities and pediatric tooth decay.

Infants who are not receiving an appropriate amount of fluoride are at increased risk for tooth decay.  Fluoride works to protect tooth enamel, simultaneously reducing mineral loss and promoting mineral reuptake.  Through a series of questionnaires and examinations, the dentist can determine whether a particular infant needs fluoride supplements or is at high-risk for baby bottle tooth decay.

What can I do at home to prevent baby bottle tooth decay?

Baby bottle tooth decay can be completely prevented by a committed parent.  Making regular dental appointments and following the guidelines below will keep each child’s smile bright, beautiful, and free of decay:

• Try not to transmit bacteria to your child via saliva exchange.  Rinse pacifiers and toys in clean water, and use a clean spoon for each person eating.
• Cleanse gums after every feeding with a clean washcloth.
• Use an appropriate toothbrush along with an ADA-approved toothpaste to brush when teeth begin to emerge.  A thin smear or grain of rice-sized amount of fluoridated toothpaste is recommended for children under the age of two. Daily ingestion of these small amounts of fluoridated toothpaste will not be harmful.
• Use a pea-sized amount of ADA-approved fluoridated toothpaste when the child has mastered the art of “spitting out” excess toothpaste. 
• Do not place sugary drinks in baby bottle or sippy cups.  Only fill these containers with water, breast milk, or formula.  Encourage the child to use a regular cup (rather than a sippy cup) when the child reaches twelve months old.
• Do not dip pacifiers in sweet liquids (honey, etc.).
• Review your child’s eating habits.  Eliminate sugar-filled snacks and encourage a healthy, nutritious diet.
• Do not allow the child to take a liquid-filled bottle to bed.  If the child insists, fill the bottle with water as opposed to a sugary alternative.
• Clean your child’s teeth until he or she reaches the age of seven.  Before this time, children are often unable to reach certain places in the mouth.
• Ask the dentist to review your child’s fluoride levels.

Does Your Child Grind His or Her Teeth at Night?

Bruxism, or the grinding of teeth, is remarkably common in children and adults.  For some children, this tooth grinding is limited to daytime hours, but nighttime grinding (during sleep) is most prevalent.  Bruxism can lead to a wide range of dental problems, depending on the frequency of the behavior, the intensity of the grinding, and the underlying causes of the grinding.

A wide range of psychological, physiological, and physical factors may lead children to brux.  In particular, jaw misalignment (bad bite), stress, and traumatic brain injury are all thought to contribute to bruxism, although grinding can also occur as a side effect of certain medications.

What are some symptoms of bruxism?

In general, parents can usually hear intense grinding – especially when it occurs at nighttime.  Subtle daytime jaw clenching and grinding, however, can be difficult to pinpoint.  Oftentimes, general symptoms provide clues as to whether or not the child is bruxing, including:

• Frequent complaints of headache.
• Injured teeth and gums.
• Loud grinding or clicking sounds.
• Rhythmic tightening or clenching of the jaw muscles.
• Unusual complaints about painful jaw muscles – especially in the morning.
• Unusual tooth sensitivity to hot and cold foods.

How can bruxism damage my child’s teeth?

Bruxism is characterized by the grinding of the upper jaw against the lower jaw.  Especially in cases where there is vigorous grinding, the child may experience moderate to severe jaw discomfort, headaches, and ear pain.  Even if the child is completely unaware of nighttime bruxing (and parents are unable to hear it), the condition of the teeth provides the dentist with important clues.

First, chronic grinders usually show an excessive wear pattern on the teeth.  If jaw misalignment is the cause, tooth enamel may be worn down in specific areas.  In addition, children who brux are more susceptible to chipped teeth, facial pain, gum injury, and temperature sensitivity.  In extreme cases, frequent, harsh grinding can lead to the early onset of temporomandibular joint disorder (TMJ).

What causes bruxism?

Bruxism can be caused by several different factors. Most commonly, “bad bite” or jaw misalignment promotes grinding.  Dentists also notice that children tend to brux more frequently in response to life stressors.  If the child is going through a particularly stressful exam period or is relocating to a new school for example, nighttime bruxing may either begin or intensify.

Children with certain developmental disorders and brain injuries may be at particular risk for grinding.  In such cases, the dentist may suggest botulism injections to calm the facial muscles, or provide a protective nighttime mouthpiece.  If the onset of bruxing is sudden, current medications need to be evaluated.  Though bruxing is a rare side effect of specific medications, the medication itself may need to be switched for an alternate brand.

How is bruxism treated?

Bruxing spontaneously ceases by the age of thirteen in the majority of children.  In the meantime however, the dentist will continually monitor its effect on the child’s teeth and may provide an interventional strategy.

In general, the cause of the grinding dictates the treatment approach.  If the child’s teeth are badly misaligned, the dentist may take steps to correct this.  Some of the available options include: altering the biting surface of teeth with crowns, and beginning occlusal treatment.

If bruxing seems to be exacerbated by stress, the dentist may recommend relaxation classes, professional therapy, or special exercises.  The child’s pediatrician may also provide muscle relaxants to alleviate jaw clenching and reduce jaw spasms.

In cases where young teeth are sustaining significant damage, the dentist may suggest a specialized nighttime dental appliance such as a nighttime mouth guard.  Mouth guards stop tooth surfaces from grinding against each other, and look similar to a mouthpiece a person might wear during sports.  Bite splints, or bite plates, fulfill the same function, and are almost universally successful in preventing grinding damage.

Early Orthodontic Treatment

Orthodontic treatment is primarily used to prevent and correct “bite” irregularities.  Several factors may contribute to such irregularities, including genetic factors, the early loss of primary (baby) teeth, and damaging oral habits (such as thumb sucking and developmental problems).

Orthodontic irregularities may be present at birth or develop during toddlerhood or early childhood.  Crooked teeth hamper self-esteem and make good oral homecare difficult, whereas straight teeth help minimize the risk of tooth decay and childhood periodontal disease.

During biannual preventative visits, the dentist is able to utilize many diagnostic tools to monitor orthodontic irregularities and, if necessary, implement early intervention strategies.  Children should have an initial orthodontic evaluation before the age of eight.

Why does early orthodontic treatment make sense?

Some children display early signs of minor orthodontic irregularities.  In such cases, the dentist may choose to monitor the situation over time without providing intervention.  However, for children who display severe orthodontic irregularities, early orthodontic treatment can provide many benefits, including:

• Enhanced self-confidence and esthetic appearance.
• Increased likelihood of proper jaw growth.
• Increased likelihood of properly aligned and spaced adult teeth.
• Reduced risk of bruxing (grinding of teeth).
• Reduced risk of childhood cavities, periodontal disease, and tooth decay.
• Reduced risk of impacted adult teeth.
• Reduced risk of protracted orthodontic treatments in later years.
• Reduced risk of speech problems.
• Reduced risk of tooth, gum, and jawbone injury.

When can my child begin early orthodontic treatment?

 Dentists recognize three age-related stages of orthodontic treatment.  These stages are described in detail below.

Stage 1: Early treatment (2-6 years old)

Early orthodontic treatment aims to guide and regulate the width of both dental arches.  The main goal of early treatment is to provide enough space for the permanent teeth to erupt correctly.  Good candidates for early treatment include: children who have difficulty biting properly, children who lose baby teeth early, children whose jaws click or grind during movement, bruxers, and children who use the mouth (as opposed to the nose AND mouth) to breathe.

During the early treatment phase, the dentist works with parents and children to eliminate orthodontically harmful habits, like excessive pacifier use and thumb sucking.  The dentist may also provide one of a variety of dental appliances to promote jaw growth, hold space for adult teeth (space maintainers), or to prevent the teeth from “shifting” into undesired areas.

Stage 2: Middle dentition (6-12 years old)

The goals of middle dentition treatments are to realign wayward jaws, to start to correct crossbites, and to begin the process of gently straightening misaligned permanent teeth.  Middle dentition marks a developmental period when the soft and hard tissues are extremely pliable.  In some ways therefore, it marks an optimal time to begin to correct a severe malocclusion.

Again, the dentist may provide the child with a dental appliance.  Some appliances (like braces) are fixed and others are removable.  Regardless of the appliance, the child will still be able to speak, eat, and chew in a normal fashion.  However, children who are fitted with fixed dental appliances should take extra care to clean the entire oral region each day in order to reduce the risk of staining, decay, and later cosmetic damage.

Stage 3: Adolescent dentition (13+ years old)

Adolescent dentition is what springs to most parents’ minds when they think of orthodontic treatment.  Some of the main goals of adolescent dentition include straightening the permanent teeth, and improving the esthetic appearance of the smile.

Most commonly during this period, the dentist will provide fixed or removable “braces” to gradually straighten the teeth.  Upon completion of the orthodontic treatment, the adolescent may be required to wear a retainer in order to prevent the regression of the teeth to their original alignment.

Eruption of Your Child’s Teeth

The eruption of primary teeth (also known as deciduous or baby teeth) follows a similar developmental timeline for most children.  A full set of primary teeth begins to grow beneath the gums during the fourth month of pregnancy. For this reason, a nourishing prenatal diet is of paramount importance to the infant’s teeth, gums, and bones.

Generally, the first primary tooth breaks through the gums between the ages of six months and one year.  By the age of three years old most children have a “full” set of twenty primary teeth.  The American Dental Association (ADA) encourages parents to make a “well-baby” appointment with a dentist approximately six months after the first tooth emerges.  Dentists communicate with parents and children about prevention strategies, emphasizing the importance of a daily home care plan.

Although primary teeth are deciduous, they facilitate speech production, proper jaw development, good chewing habits – and the proper spacing and alignment of adult teeth.  Caring properly for primary teeth helps defend against painful tooth decay, premature tooth loss, malnutrition, and childhood periodontal disease.

In what order do primary teeth emerge?

As a general rule-of-thumb, the first teeth to emerge are the central incisors (very front teeth) on the lower and upper jaws (6-12 months).  These (and any other primary teeth) can be cleaned gently with a soft, clean cloth to reduce the risk of bacterial infection.  The central incisors are the first teeth to be lost, usually between 6 and 7 years of age.

Next, the lateral incisors (immediately adjacent to the central incisors) emerge on the upper and lower jaws (9-16 months).  These teeth are lost next, usually between 7 and 8 years of age.  First molars, the large flat teeth towards the rear of the mouth then emerge on the upper and lower jaws (13-19 months).  The eruption of molars can be painful.  Clean fingers, cool gauzes, and teething rings are all useful in soothing discomfort and soreness. First molars are generally lost between 9 and 11 years of age.

Canine (cuspid) teeth then tend to emerge on the upper and lower jaws (16-23 months).  Canine teeth can be found next to the lateral incisors, and are lost during preadolescence (10-12 years old).  Finally, second molars complete the primary set on the lower and upper jaw (23-33 months).  Second molars can be found at the very back of the mouth, and are lost between the ages of 10 and 12 years old.

What else is known about primary teeth?

Though each child is unique, baby girls generally have a head start on baby boys when it comes to primary tooth eruption.  Lower teeth usually erupt before opposing upper teeth in both sexes.

Teeth usually erupt in pairs – meaning that there may be months with no new activity and months where two or more teeth emerge at once.  Due to smaller jaw size, primary teeth are smaller than permanent teeth, and appear to have a whiter tone.  Finally, an interesting mixture of primary and permanent teeth is the norm for most school-age children.

Fluoride

If you have questions or concerns about fluoride or fluorosis, please contact your dentist.

Fluorine, a natural element in the fluoride compound, has proven to be effective in minimizing childhood cavities and tooth decay.  Fluoride is a key ingredient in many popular brands of toothpaste, oral gel, and mouthwash, and can also be found in most community water supplies. Though fluoride is an important part of any good oral care routine, overconsumption can result in a condition known as fluorosis. Fluorosis in the Sacramento region is extremely rare and is usually associated with excessive use of prescription ingested fluoride.

How can fluoride prevent tooth decay?

Fluoride fulfills two important dental functions.  First, it helps to staunch mineral loss from tooth enamel, and second, it promotes the remineralization of tooth enamel.

When carbohydrates (sugars) are consumed, oral bacteria feed on them and produce harmful acids.  These acids attack tooth enamel – especially in children who take medications or produce less saliva.  Repeated acid attacks result in cavities, tooth decay, and childhood periodontal disease.  Fluoride protects tooth enamel from acid attacks and reduces the risk of childhood tooth decay.

Fluoride is especially effective when used as part of a good oral hygiene regimen.  Reducing the consumption of sugary foods, brushing and flossing regularly, and visiting the dentist biannually, all supplement the work of fluoride and keep young teeth healthy.

How much fluoride is enough?

Since community water supplies and toothpastes usually contain fluoride, it is essential that children do not ingest too much.  Children under the age of two should only use a grain or rice-sized amount of ADA-approved fluoridated tooth paste when brushing.  Children over the age of two, who can spit on command, should use a pea-sized amount of ADA-approved fluoridated toothpaste on a clean toothbrush twice each day. 

The amount of fluoride children ingest between the ages of one and four years old determines whether or not fluorosis occurs later.  The most common symptom of fluorosis is white specks on the permanent teeth.  Children over the age of eight years old are not considered to be at-risk for fluorosis, but should still use an ADA-approved brand of toothpaste.

Does my child need fluoride supplements?

The dentist is the best person to decide whether a child needs fluoride supplements.  First, the dentist will ask questions in order to determine how much fluoride the child is currently receiving, gain a general health history, and evaluate the sugar content in the child’s diet.  If a child is not receiving enough fluoride and is determined to be at high-risk for tooth decay, an at-home fluoride supplement may be recommended.

Topical fluoride can also be applied to the tooth enamel quickly and painlessly during a regular office visit.  There are many convenient forms of topical fluoride, including foam, liquids, varnishes, and gels.  Depending on the age of the child and their willingness to cooperate, topical fluoride can be painted on with a brush.

Is my tap water fluoridated?

Copy and paste the following link to see a map of water fluoridation in Sacramento County. If you live in an area that is not currently fluoridated, please let Dr. Kristy or Dr. Joel know so that they can write your child a prescription for fluoride supplements.
https://first5sacramento.saccounty.net/Programs/Documents/COS_Fluoridation_Map.pdf#search=fluoridation%20map

Good Diet

A child’s general level of health often dictates his or her oral health, and vice versa.  Therefore, supplying children with a well-balanced diet is more likely to lead to healthier teeth and gums.  A good diet provides the child with the many different nutrients he or she needs to grow.  These nutrients are necessary for gum tissue development, strong bones, and to protect the child against certain illnesses.

According to the MyPlate diagram, children need vegetables, fruits, protein, grains, and dairy products to grow properly.  These different food groups should be eaten in balance for optimal results.

How does my child’s diet affect his or her teeth?

Almost every snack contains at least one type of sugar.  Most often, parents are tempted to throw away candy and chocolate snacks – without realizing that many fruit snacks contain one (if not several) types of sugar or carbohydrate.  When sugar-rich snacks are eaten, the sugar content attracts oral bacteria. The bacteria feast on food remnants left on or around the teeth.  Eventually, feasting bacteria produce enamel-attacking acids.

When tooth enamel is constantly exposed to acid, it begins to erode – the result is childhood tooth decay.  If tooth decay is left untreated the decay will spread to other teeth and cause the teeth to break or allow infection to invade into the tooth and jaw bone.

Regular checkups and cleanings at the dentist’s office are an important line of defense against tooth decay.  However, implementing good dietary habits and minimizing sugary food and drink intake as part of the “home care routine” are equally important.

How can I alter my child’s diet?

The dentist, dental hygienist and dental assistants are able to offer advice and dietary counseling for children and parents.  Most often, parents are advised to opt for healthier snacks, for example, carrot sticks, reduced fat yoghurt, and cottage cheese.  In addition, a fluoride supplement may be recommended to protect tooth enamel – especially if the child lives in an area where fluoride is not routinely added to community water.

Parents should also ensure that children are not continuously snacking – even in a healthy manner.  Lots of snacking means that sugars are constantly attaching themselves to teeth, and tooth enamel is constantly under attack.  It is also impractical to try to clean the teeth after every snack, if “every snack” means every ten minutes!

Finally, parents are advised to opt for faster snacks.  Mints and hard candies remain in the mouth for a long period of time – meaning that sugar is coating the teeth for longer.  If candy is necessary, opt for a sugar-free variety, or a variety that can be eaten expediently.

Should my child eat starch-rich foods?

It is important for the child to eat a balanced diet, so some carbohydrates and starches are necessary.  Starch-rich foods generally include pretzels, chips, and peanut butter and jelly sandwiches.  Since starches and carbohydrates break down to form sugar, it is best that they are eaten as part of a meal (when saliva production is higher), rather than as a standalone snack.  Provide plenty of water at mealtimes (rather than soda) to help the child rinse sugary food particles off the teeth.

As a final dietary note, avoid feeding your child sticky foods if possible.  It is incredibly difficult to remove stickiness from the teeth – especially in younger children who tend not to be as patient during brushing.

How Often Should Children Have Dental Checkups?

The American Academy of Pediatric Dentists (AAPD) advises parents to make biannual dental appointments for children, beginning approximately six months after the first tooth emerges.

These two important yearly visits allow the dentist to monitor new developments in the child’s mouth, evaluate changes in the condition of teeth and gums, and continue to advise parents on good oral care strategies.

The dentist may schedule additional visits for children who are particularly susceptible to tooth decay or who show early signs of orthodontic problems.

What is the purpose of dental checkups?

First, the dentist aims to provide a “good dental home” for the child.  If a dental emergency does arise, parents can take the child for treatment at a familiar, comfortable location.

Second, the dentist keeps meticulous records of the child’s ongoing dental health and jaw development.  In general, painful dental conditions do not arise overnight.  If the dentist understands the child’s dental health history, it becomes easier to anticipate future issues and intervene before they arise.

Third, the dentist is able to educate parents and children during the visit.  Sometimes the dentist wants to introduce one or several factors to enhance tooth health – for example, sealants, fluoride supplements, or xylitol.  Other times, the pediatric dentist asks parents to change the child’s dietary or oral behavior – for example, reducing sugar in the child’s diet, removing an intraoral piercing, or even transitioning the child from sippy cups to adult-sized drinking glasses.

Finally, dental X-rays are often the only way to identify tiny cavities in primary (baby) teeth.  Though the child may not be feeling any pain, left unchecked, these tiny cavities can rapidly turn into large cavities, tooth decay, and eventually, childhood periodontal disease.  Dental X-rays are only used when the dentist suspects cavities or orthodontic irregularities.

Are checkups necessary if my child has healthy teeth?

The condition of a child’s teeth can change fairly rapidly.  Even if the child’s teeth were evaluated as healthy just six months prior, changes in diet or oral habits (for example, thumb sucking) can quickly render them vulnerable to decay or misalignment.

In addition to visual examinations, the dentist provides thorough dental cleanings during each visit.  These cleanings eradicate the plaque and debris that can build up between teeth and in other hard to reach places.  Though a good homecare routine is especially important, these professional cleanings provide an additional tool to keep smiles healthy.

The dentist is also able to monitor the child’s fluoride levels during routine visits.  Oftentimes, a topical fluoride gel or varnish is applied to teeth after the cleaning.  Topical fluoride remineralizes the teeth and staunches mineral loss, protecting tooth enamel from oral acid attacks.  Some children are also given take-home fluoride supplements (especially those residing in areas where fluoride is not routinely added to the community water supply).

Finally, the dentist may apply dental sealants to the child’s back teeth (molars).  This impenetrable liquid plastic substance is brushed onto the molars to seal out harmful debris, bacteria, and acid.

How to Prevent Cavities

Childhood cavities, also known as childhood tooth decay and childhood caries, are common in children all over the world.  There are two main causes of cavities: poor dental hygiene and sugary diets.

Cavities can be incredibly painful, often leading to tooth decay and childhood periodontitis if left untreated.  Ensuring that children eat a balanced diet, embarking on a sound home oral care routine, and visiting the pediatric dentist biannually, are all crucial factors for both cavity prevention and excellent oral health.

What causes cavities?

Cavities form when children’s teeth are exposed to sugary foods on a regular basis.  Sugars and carbohydrates (like the ones found in white bread) collect on and around the teeth after eating.  A sticky film (plaque) then forms on the tooth enamel.  The oral bacteria within the plaque continually ingest sugar particles and emit acid.  Initially, the acid attacks the tooth enamel, weakening it and leaving it vulnerable to tooth decay.  If conditions are allowed to worsen, the acid begins to penetrate the tooth enamel and erodes the inner workings of the tooth.

Although primary (baby) teeth are eventually lost, they fulfill several important functions and should be protected.  It is essential that children brush and floss twice per day (ideally more), and visit the dentist for biannual cleanings.  Sometimes the pediatric dentist coats teeth with a sealant and provides fluoride supplements to further bolster the mouth’s defenses.

How will I know if my child has a cavity?

Large cavities can be excruciatingly painful, whereas tiny cavities may not be felt at all.  Making matters even trickier, cavities sometimes form between the teeth, making them invisible to the naked eye.  Dental X-rays and the dentist’s trained eyes help pinpoint even the tiniest of cavities so they can be treated before they worsen.

Some of the major symptoms of cavities include:

• Heightened sensitivity to cool or warm foods
• Nighttime waking and crying
• Pain
• Sensitivity to spicy foods
• Toothache

If a child is experiencing any of these symptoms, it is important to visit the pediatric dentist.  Failure to do so will make the problem worse, leave the child in pain, and could possibly jeopardize a tooth that could have been treated.

How can I prevent cavities at home?

Biannual visits with the pediatric dentist are only part of the battle against cavities.  Here are some helpful guidelines for cavity prevention:

1. Analyze the diet – Too many sugary or starchy snacks can expedite cavity formation.  Replace sugary snacks like candy with natural foods where possible, and similarly replace soda with water.
2. Cut the snacks – Snacking too frequently can unnecessarily expose teeth to sugars.  Save the sugar and starch for mealtimes, when the child is producing more saliva, and drinking water.  Make sure they consume enough water to cleanse the teeth.
3. Lose the sippy cup – Sippy cups are thought to cause “baby bottle tooth decay” when they are used beyond the intended age (approximately twelve months).  The small amount of liquid emitted with each sip causes sugary liquid to continually swill around the teeth.
4. Avoid stickiness – Sticky foods (like toffee or dried fruits) form plaque quickly, and are extremely difficult to pry off the teeth.  Avoid them where possible.
5. Rinse the pacifier – Oral bacteria can be transmitted from mother or father to baby.  Rinse a dirty pacifier with running water as opposed to sucking on it, to avoid contaminating the baby’s mouth.
6. Drinks at bedtime – Sending a child to bed with a bottle or sippy cup is bad news.  The milk, formula, juice, or sweetened water basically sits on the teeth all night – attacking enamel and maximizing the risk of cavities.  Ensure the child has a last drink before bedtime, and then brush the teeth.
7. Don’t sweeten the pacifier – Parents sometimes dip pacifiers in honey to calm a cranky child.  Do not be tempted to do this.  Use a blanket, toy, or hug to calm the child instead.
8. Brush and floss – Parents should brush and floss their child’s teeth twice each day until the child reaches the age of seven years old.  Before this time, children struggle to brush every area of the mouth effectively.
9. Check on fluoride –When used correctly, fluoride can strengthen tooth enamel and help stave off cavities.  Too much or too little fluoride can actually harm the teeth, so ask the pediatric dentist for a fluoride assessment.
10. Keep to appointments – The child’s first dental visit should be scheduled around his or her first birthday, as per the American Academy of Pediatric Dentistry (AAPD) guidelines.  Keep to a regular appointment schedule to create healthy smiles!

Pacifiers and Thumb Sucking

For most infants, the sucking of thumbs and pacifiers is a happy, everyday part of life.  Since sucking is a natural, instinctual baby habit, infants derive a sense of comfort, relaxation, and security from using a thumb or pacifier as a sucking aid.

According to research from the American Academy of Pediatric Dentistry (AAPD), the vast majority of children will cease using a pacifier before the age of four years old.  Thumb sucking can be a harder habit to break and tends to persist for longer without intervention.  Children who continue to suck thumbs or pacifiers after the age of five (and particularly those who continue after permanent teeth begin to emerge) are at high-risk for developing dental complications.

How can thumb sucking and pacifier use damage children’s teeth?

Pacifier and thumb sucking damage can be quite insidious.  Both can be difficult to assess with the naked eye, and both tend to occur over a prolonged period of time.  Below is an overview of some of the risks associated with prolonged thumb sucking and pacifier use:

Jaw misalignment – Pacifiers come in a wide range of shapes and sizes, most of which are completely unnatural for the mouth to hold.  Over time, pacifiers and thumbs can guide the developing jaws out of correct alignment.

Tooth decay – Many parents attempt to soothe infants by dipping pacifiers in honey, or some other sugary substance.  Oral bacteria feed on sugar and emit harmful acids.  The acids attack tooth enamel and can lead to pediatric tooth decay and childhood caries.

Roof narrowing – The structures in the mouth are extremely pliable during childhood.  Prolonged, repeated exposure to thumb and pacifier sucking actually cause the roof of the mouth to narrow (as if molding around the sucking device).  This can cause later problems with developing teeth.

Slanting teeth – Growing teeth can be caused to slant or protrude by thumb and pacifier sucking, leading to poor esthetic results.  In addition, thumb sucking and pacifier use in later childhood increases the need for extensive orthodontic treatments.

Mouth sores – Passive sucking is much less harmful than aggressive sucking.  Aggressive sucking (popping sounds when the child sucks) may cause sores or ulcers to develop.

If you do intend to purchase a pacifier:

• Buy a one-piece pacifier to reduce the risk of choking.
• Buy an “orthodontically correct” model.
• Do not dip it in honey or any other sugary liquid.
• Rinse with water (as opposed to cleansing with your mouth) to prevent bacterial transmissions.

How can I encourage my child to stop thumb or pacifier sucking?

In most cases, children naturally relinquish the pacifier or thumb over time.  As children grow, they develop new ways to self-soothe, relax, and entertain themselves.  When thumb sucking or pacifier use persists past the age of five, a gentle intervention may be required.

Here are some helpful suggestions to help encourage the child to cease thumb sucking or pacifier use:

• Ask the pediatric dentist to speak with the child about stopping.  Often, the message is heard more clearly when delivered by a health professional.
• Buy an ADA recommended specialized dental appliance to make it difficult for the child to engage in sucking behaviors.
• Implement a reward system (not a punishment), whereby the child can earn tokens or points towards a desirable reward for not thumb sucking or using a pacifier.
• Wrap thumbs in soft cloths or mittens at nighttime.

If the above suggestions do not seem to be working, your pediatric dentist can provide more guidance.  Remember: the breaking of a habit takes time, patience, and plenty of encouragement!

Perinatal and Infant Oral Health

Pregnancy is an exciting time. It is also a crucially important time for the unborn child’s oral and overall health.  The “perinatal” period begins approximately 20-28 weeks into the pregnancy, and ends 1-4 weeks after the infant is born.  With so much to do to prepare for the new arrival, a dental checkup is often the last thing on an expectant mother’s mind.

Research shows, however, that there are links between maternal periodontal disease (gum disease) and premature babies, babies with low birth weight, maternal preeclampsia, and gestational diabetes.  It is of paramount importance therefore, for mothers to maintain excellent oral health throughout the entire pregnancy.

Why are perinatal dental checkups important?

Maternal cariogenic bacteria is linked with a wide range of adverse outcomes for infants and young children.  For this reason, the American Academy of Pediatric Dentistry (AAPD) advises expectant mothers to get dental checkups and counseling regularly, for the purposes of prevention, intervention, and treatment.

Here are some perinatal oral care tips for expectant mothers:

• Brush and floss – Be sure to use an ADA approved, fluoridated toothpaste at least twice each day, and floss at least once each day, to eliminate harmful oral bacteria.  In addition, an alcohol-free mouthwash should be used on a daily basis.
• Chew gum – Xylitol, a natural substance, has been shown to reduce infant and toddler caries (cavities) when chewed 3-5 times daily by the expectant mother.  When choosing gum, check for the “xylitol” ingredient – no other sugar substitute has proven to be beneficial in clinical studies.
• Diet evaluation – Maintaining a balanced, nourishing diet is always important, but particularly so during pregnancy.  Make a food eating diary and look for ways to cut down on sugary and starchy foods.  Sugars and starches provide food for oral bacteria, and also increase the risk of tooth decay.
• Make regular dental appointments – When seen regularly, the dentist can bolster homecare preventative efforts and provide excellent advice.  The dentist is able to check the general condition of teeth and provide strategies for reducing oral bacteria.

How can I care for my infant’s gums and teeth?

Many parents do not realize that cavity-causing (cariogenic) bacteria can be transmitted from the mother or father to the child.  This transmission happens via the sharing of eating utensils and the “cleaning” of pacifiers in the parent’s mouth.  Parents should endeavor to use different eating utensils from their infants and to rinse pacifiers with warm water as opposed to sucking them.

Parents should also adhere to the following guidelines to enhance infant oral health:

• Brush – Using a soft-bristled toothbrush and a tiny sliver of ADA approved non-fluoridated toothpaste (for children under two), gently brush the teeth twice each day.
• Floss – As soon as two adjacent teeth appear in the infant’s mouth, cavities can form between the teeth.  Ask the pediatric dentist for advice on the best way to floss the infant’s teeth.
• Pacifier use – Pacifiers are a soothing tool for infants.  If you decide to purchase a pacifier, choose an orthodontically correct model (you can ask the pediatric dentist for recommendations).  Be sure not to dip pacifiers in honey or any other sweet liquid.
• Use drinking glasses – Baby bottles and sippy cups are largely responsible for infant and toddler tooth decay.  Both permit a small amount of liquid to repeatedly enter the mouth.  Consequently, sugary liquid (milk, soda, juice, formula, breast milk or sweetened water) is constantly swilling around in the infant’s mouth, fostering bacterial growth and expediting tooth decay.  Only offer water in sippy cups, and discontinue their use after the infant’s first birthday.
• Visit the dentist – Around the age of one, the infant should visit a dentist for a “well baby” appointment.  The dentist will examine tooth and jaw development, and provide strategies for future oral care.
• Wipe gums – The infant is at risk for early cavities as soon as the first tooth emerges.  For young infants, wipe the gums with a damp cloth after every feeding.  This reduces oral bacteria and minimizes the risk of early cavities.

What is Pulp Therapy?

The “pulp” of a tooth cannot be seen with the naked eye. Pulp is found at the center of each tooth, and is comprised of nerves, tissue, and many blood vessels, which work to channel vital nutrients and oxygen.  There are several ways in which pulp can be damaged.  Most commonly in children, tooth decay or traumatic injury lead to painful pulp exposure and inflammation.

Pediatric pulp therapy is known by several other names, including: root canal, pulpotomy, pulpectomy, and nerve treatment.  The primary goal of pulp therapy is to treat, restore, and save the affected tooth.

Dentists perform pulp therapy on both primary (baby) teeth and permanent teeth.  Though primary teeth are eventually shed, they are needed for speech production, proper chewing, and to guide the proper alignment and spacing of permanent teeth.

What are the signs of pulp injury and infection?

Inflamed or injured pulp is exceptionally painful.  Even if the source of the pain isn’t visible, it will quickly become obvious that the child needs to see the dentist.

Here are some of the other signs to look for:

• Constant unexplained pain.
• Nighttime pain.
• Sensitivity to warm and cool food temperatures.
• Swelling or redness around the affected tooth.
• Unexpected looseness or mobility of the affected tooth.

When should a child undergo pulp therapy?

Every situation is unique.  The pediatric dentist assesses the age of the child, the positioning of the tooth, and the general health of the child before making a recommendation to extract the tooth or to save it via pulp therapy.

Some of the undesirable consequences of prematurely extracted/missing teeth are listed below:

• Arch length may shorten.
• In the case of primary tooth loss, permanent teeth may lack sufficient space to emerge.
• Opposing teeth may grow in a protruding or undesirable way.
• Premolars may become painfully impacted.
• Remaining teeth may “move” to fill the gap.
• The tongue may posture abnormally.

How is pulp therapy performed?

Initially, the dentist will perform visual examinations and evaluate X-rays of the affected areas.  The amount and location of pulp damage dictates the nature of the treatment.  Although there are several other treatments available, the pediatric pulpotomy and pulpectomy procedures are among the most common performed.

Pulpotomy – If the pulp root remains unaffected by injury or decay, meaning that the problem is isolated in the pulp tip, the pediatric dentist may leave the healthy part alone and only remove the affected pulp and surrounding tooth decay.  The resulting gap is then filled with a biocompatible, therapeutic material, which prevents infection and soothes the pulp root. Most commonly, a crown is placed on the tooth after treatment.  The crown strengthens the tooth structure, minimizing the risk of future fractures.

Pulpotomy treatment is extremely versatile.  It can be performed as a standalone treatment on baby teeth and growing permanent teeth, or as the initial step in a full root canal treatment.

Pulpectomy – In the case of severe tooth decay or trauma, the entire tooth pulp (including the root canals) may be affected.  In these circumstances, the pediatric dentist must remove the pulp, cleanse the root canals, and then pack the area with biocompatible material.  This usually takes several office visits.

In general, reabsorbable material is used to fill primary teeth, and non-reabsorbable material is used to fill permanent teeth.  Either way, the final treatment step is to place a crown on the tooth to add strength and provide structural support.  The crown can be disguised with a natural-colored covering, if the child prefers.

What’s the Best Toothpaste for My Child?

Evaluating the many brands of oral products claiming to be “best for children” can be an overwhelming task.  Selecting an appropriately sized toothbrush and a fluoridated, cleansing brand of children’s toothpaste is of paramount importance for maintaining excellent oral health.

Why brush primary teeth?

The importance of maintaining the health of primary (baby) teeth is often understated.  Primary teeth are essential for speech production, chewing, jaw development, and they also facilitate the proper alignment and spacing of permanent adult teeth.  Brushing primary teeth prevents bad breath and tooth decay, and also removes the plaque bacteria associated with childhood periodontal disease.

What differences are there among toothpaste brands?

Though all toothpastes are not created equal, most brands generally contain abrasive ingredients to remove stains, soapy ingredients to eliminate plaque, fluorides to strengthen tooth enamel, and some type of pleasant-tasting flavoring.

The major differences between brands are the thickness of the paste, the level of fluoride content, and the type of flavoring.  Although fluoride strengthens enamel and repels plaque bacteria, too much of it can actually harm young teeth – a condition known as dental fluorosis.  Children between the ages of one and four years old are most at risk for this condition, so fluoride levels should be carefully monitored during this time. If your child cannot spit on command, only use a thin smear or grain or rice-sized amount of toothpaste for brushing teeth.

Be aware that adult and non-ADA approved brands of toothpaste often contain harsher abrasives, which remove tooth enamel and weaken primary teeth.  In addition, some popular toothpaste brands contain sodium lauryl sulfate (shown as “SLS” on the package), which cause mouth ulcers in some children.

So which toothpaste brand should I choose?

The most important considerations to make before implementing an oral care plan and choosing a toothpaste brand is the age of the child.  Home oral care should begin before the emergence of the first tooth.  A cool clean cloth should be gently rubbed along the gums after feeding to remove food particles and bacteria.

Prior to the age of two, the child will have many teeth and brushing should begin.  Initially, select fluoride-free “baby” toothpaste and softly brush the teeth twice per day.  Flavoring is largely unimportant, so the child can play an integral role in choosing whatever type of toothpaste tastes most pleasant.

Between the middle and the end of the third year, select an American Dental Association (ADA) accepted brand of toothpaste containing fluoride.  The ADA logo is clear and present on toothpaste packaging, so be sure to check for it.  Use only a tiny pea or rice-sized amount of fluoride toothpaste, and encourage the child to spit out the excess after brushing.  Spitting toothpaste out after brushing takes practice, patience, and motivation – especially if the child finds the flavoring tasty.  If the child does ingest tiny amounts of toothpaste, don’t worry; this is perfectly normal and will cease with time and encouragement.

Dental fluorosis is not a risk factor for children over the age of eight, but an ADA accepted toothpaste is always the recommended choice for children of any age.

When Should Children Have Their First Dental Visit?

The American Academy of Pediatric Dentistry (AAPD) suggests that parents should make an initial “well-baby” appointment with a dentist approximately six months after the emergence of the first tooth, or no later than the child’s first birthday.

Although this may seem surprisingly early, the incidence of infant and toddler tooth decay has been rising in recent years.  Tooth decay and early cavities can be exceptionally painful if they are not attended to immediately, and can also set the scene for poor oral health in later childhood.

Oftentimes, the dentist can provide strategies for eliminating unwanted oral habits (for example, pacifier use and thumb sucking) and can also help parents in establishing a sound daily oral routine for the child.

What potential dental problems can babies experience?

A baby is at risk for tooth decay as soon as the first tooth emerges.  During the first visit, the dentist will help parents implement a preventative strategy to protect the teeth from harm, and also demonstrate how infant teeth should be brushed and flossed.

In particular, infants who drink breast milk, juice, baby formula, soda, or sweetened water from a baby bottle or sippy cup are at high-risk for early childhood caries (cavities).  To counteract this threat, the pediatric dentist discourages parents from filling cups with sugary fluids, dipping pacifiers in honey, and transmitting oral bacteria to the child via shared spoons and/or cleaning pacifiers in their own mouths.

Importantly, the pediatric dentist can also assess and balance the infant’s fluoride intake.  Too much fluoride ingestion between the ages of one and four years old may lead to a condition known as fluorosis in later childhood.  Conversely, too little fluoride may render young tooth enamel susceptible to tooth decay.

What happens during the first visit?

During the initial visit, the pediatric dentist will advise parents to implement a good oral care routine, ask questions about the child’s oral habits, and examine the child’s emerging teeth.  The pediatric dentist and parent sit knee-to-knee for this examination to enable the child to view the parent at all times.  If the infant’s teeth appear stained, the dentist may clean them.  Oftentimes, a topical fluoride treatment will be applied to the teeth after this cleaning.

What questions may the pediatric dentist ask during the first visit?

The pediatric dentist will ask questions about current oral care, diet, the general health of the child, the child’s oral habits, and the child’s current fluoride intake.

Once answers to these questions have been established, the pediatric dentist can advise parents on the following issues:

• Accident prevention.
• Adding xylitol and fluoride to the infant’s diet.
• Choosing an ADA approved, non-fluoridated brand of toothpaste for the infant.
• Choosing an appropriate toothbrush.
• Choosing an orthodontically correct pacifier.
• Correct positioning of the head during tooth brushing.
• Easing the transition from sippy cup to adult-sized drinking glasses (12-14 months).
• Eliminating fussing during the oral care routine.
• Establishing a drink-free bedtime routine.
• Maintaining good dietary habits.
• Minimizing the risk of tooth decay.
• Reducing sugar and carbohydrate intake.
• Teething and developmental milestones.

When Will My Baby Start Getting Teeth?

The initial growth period for primary (baby) teeth begins in the second trimester of pregnancy (around 16-20 weeks).  During this time, it is especially important for expectant mothers to eat a healthy, nutritious diet, since nutrients are needed for bone and soft tissue development.

Though there are some individual differences in the timing of tooth eruption, primary teeth usually begin to emerge when the infant is between six and eight months old.  Altogether, a set of twenty primary teeth will emerge by the age of three.

The American Academy of Pediatric Dentistry (AAPD) recommends a first “well-baby” dental visit around the age of twelve months (or six months after the first tooth emerges).  This visit acquaints the infant with the dental office, allows the pediatric dentist to monitor development, and provides a great opportunity for parents to ask questions.

Which teeth emerge first?

In general, teeth emerge in pairs, starting at the front of the infant’s mouth.  Between the ages of six and ten months, the two lower central incisors break through.  Remember that cavities may develop between two adjacent teeth, so flossing should begin at this point.

Next (and sometimes simultaneously), the two upper central incisors emerge – usually between the ages of eight and twelve months.  Teething can be quite an uncomfortable process for the infant.  Clean teething rings and cold damp cloths can help ease the irritation and discomfort.

Between the ages of nine and sixteen months the upper lateral incisors emerge – one on either side of the central incisors.  Around the same time, the lower lateral incisors emerge, meaning that the infant has four adjacent teeth on the lower and upper arches.  Pediatric dentists suggest that sippy cup usage should end when the toddler reaches the age of fourteen months. This minimizes the risk of “baby bottle tooth decay.”

Eight more teeth break through between the ages of thirteen and twenty three months.  On each arch, a cuspid or canine tooth will appear immediately adjacent to each lateral incisor.  Immediately behind (looking towards the back of the child’s mouth), first molars will emerge on either side of the canine teeth on both jaws.

Finally, a second set of molars emerges on each arch – usually beginning on the lower arch.  Most children have a complete set of twenty primary teeth before the age of thirty-three months.  The pediatric dentist generally applies dental sealant to the molars, to lock out food particles, bacteria, and enamel-attacking acids.

How can I reduce the risk of early caries (cavities)?

Primary teeth preserve space for permanent teeth and guide their later alignment.  In addition, primary teeth help with speech production, prevent the tongue from posturing abnormally, and play an important role in the chewing of food.  For these reasons, it is critically important to learn how to care for the child’s emerging teeth.

Here are some helpful tips:

1. Brush twice each day – The AAPD recommends a rice grain-sized amount of ADA approved (fluoridated) toothpaste for children under two years old, and pea-sized amount of an ADA approved (fluoridated) toothpaste for children over this age.  The toothbrush should be soft-bristled and appropriate for the child’s dental developmental age. You can ask the dentist what your child’s dental developmental age is at their biannual visit.
2. Start flossing – Flossing an infant’s teeth can be difficult but the process should begin when two adjacent teeth emerge.  The pediatric dentist will happily demonstrate good flossing techniques.
3. Provide a balanced diet – Sugars and starches feed oral bacteria, which produce harmful acids and attack tooth enamel.  Ensure that the child is eating a balanced diet and work to reduce sugary and starchy snacks.
4. Set a good example – Children who see parents brushing and flossing are often more likely to follow suit.  Explain the importance of good oral care to the child; age-appropriate books often help with this.
5. Visit the dentist – The pediatric dentist monitors oral development, provides professional cleanings, applies topical fluoride to the teeth, and coats molars with sealants.  Biannual trips to the dental office can help to prevent a wide range of painful conditions later.

Why Are Primary Teeth Important?

Primary teeth, also known as “baby teeth” or “deciduous teeth,” begin to develop beneath the gums during the second trimester of pregnancy.  Teeth begin to emerge above the gums approximately six months to one year after birth.  Typically, preschool children have a complete set of 20 baby teeth – including four molars on each arch.

One of the most common misconceptions about primary teeth is that they are irrelevant to the child’s future oral health.  However, their importance is emphasized by the American Dental Association (ADA), which urges parents to schedule a “baby checkup” with a dentist within six months of the first tooth emerges.

What are the functions of primary teeth?

Primary teeth can be painful to acquire.  To soothe tender gums, biting on chewing rings, wet gauze pads, and clean fingers can be helpful.  Though most three-year-old children have a complete set of primary teeth, eruption happens gradually – usually starting at the front of the mouth.

The major functions of primary teeth are described below:

Speech production and development – Learning to speak clearly is crucial for cognitive, social, and emotional development.  The proper positioning of primary teeth facilitates correct syllable pronunciation and prevents the tongue from straying during speech formation.

Eating and nutrition – Children with malformed or severely decayed primary teeth are more likely to experience dietary deficiencies, malnourishment, and to be underweight.  Proper chewing motions are acquired over time and with extensive practice.  Healthy primary teeth promote good chewing habits and facilitate nutritious eating.

Self-confidence – Even very young children can be quick to point out ugly teeth and crooked smiles.  Taking good care of primary teeth can make social interactions more pleasant, reduce the risk of bad breath, and promote confident smiles and positive social interactions.

Straighter smiles – One of the major functions of primary teeth is to hold an appropriate amount of space for developing adult teeth.  In addition, these spacers facilitate the proper alignment of adult teeth and also promote jaw development.  Left untreated, missing primary teeth cause the remaining teeth to “shift” and fill spaces improperly.  For this reason, pediatric dentists often recommend space-maintaining devices.

Excellent oral health – Badly decayed primary teeth can promote the onset of childhood periodontal disease.  As a result of this condition, oral bacteria invade and erode gums, ligaments, and eventually bone.  If left untreated, primary teeth can drop out completely – causing health and spacing problems for emerging permanent teeth.  To avoid periodontal disease, children should practice an adult-guided oral care routine each day, and infant gums should be rubbed gently with a clean, damp cloth after meals.

Xylitol – Reducing Cavities

Tooth decay is a common, yet preventable childhood problem.  Left untreated, cavities in primary (baby) and permanent (adult) teeth become painful and negatively impact the esthetics and functionality of the teeth.

Some children are particularly susceptible to tooth decay, even after receiving regular dental examinations and oral care at home.  The American Academy of Pediatric Dentistry (AAPD) has recently recognized the benefits of a substance called xylitol for reducing childhood tooth decay.

What is xylitol?

Xylitol is a natural substance that can be found in a variety of fruits and vegetables.  Some of the most common xylitol- rich foods include: berries, mushrooms, corns, and lettuces.  Study results indicate that 4-20 grams of xylitol each day, divided into three or more helpings, can reduce tooth decay and cavities by as much as 70%.  As a point of reference, a single cup of berries contains a little less than one gram of xylitol.

It can be difficult to encourage children (especially toddlers) to consistently eat four or more cups of fruit or vegetables each day.  For this reason, xylitol is also available as a sugar substitute, a gum, and as a concentrate in numerous health foods. No other sugar substitute has been shown to benefit young teeth in the same way.

It should be noted that excessive xylitol consumption does not provide “more” tooth protection.  Sticking to the recommended daily amount is enough to enhance other cavity-reduction efforts, and the effects will last well into the future.

How does xylitol work?

The combination of many factors increases susceptibility to childhood tooth decay and cavities.  These factors include: oral care habits, diet, carbohydrate consumption, sucrose consumption, salivary flow rate, and tooth resistance to plaque.

More specifically, harmful oral bacteria feed on sugars and carbohydrates, producing acids.  When sugary foods are consumed, these acids attack and destroy vulnerable tooth enamel. Xylitol works to neutralize the acids, reducing enamel destruction, and minimizing the threat of cavities in the process.  Xylitol also stimulates saliva production, meaning that food particles, plaque and bacteria are continually removed from the teeth.  When used in combination with fluoride, xylitol works to remineralize teeth, protecting tooth enamel and minimizing new cavity formation.

When should my child start using xylitol?

Although xylitol gum is not suitable for very young children, infants actually benefit from maternal chewing!  Mothers of children between three months and two years old who used xylitol gum several times each day, protected their child from tooth decay until the age of five years old.  In this case, xylitol reduced the amount of microorganisms transmitted from mother to child.

Once the child reaches toddlerhood, xylitol can be consumed as a sugar substitute, or as a natural byproduct of eating fruit and vegetables.  Older children can reduce the threat of new cavities by chewing xylitol gum.