Pediatric Dentistry

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

Baby teeth aid in speech development and enunciation, 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 an increased risk of disease.

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 or 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 or guardian. Making regular dental appointments and following the guidelines below will keep each child’s smile bright, beautiful, and free of decay:

Cleanse gums after every feeding with a clean washcloth or toothbrush.

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.

Use an appropriate toothbrush along with an ADA-approved toothpaste to brush when teeth begin to emerge. We recommend using fluoride toothpaste as long as only a tiny smear is added to the brush and then the child’s mouth manually rinsed with water. Fluoride-free toothpaste is recommended for children who do not know how to spit out the paste or guardians that do not know how much toothpaste to use.

Use a pea-sized amount of ADA-approved fluoridated toothpaste when the child has mastered the art of “spitting out” excess toothpaste. Though fluoride is important for the teeth, too much consumption can result in a condition called fluorosis.

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.

Pediatric oral care has two main components: preventative care at the dentist’s office and preventative care at home. Though infant and toddler caries or 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 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. Oral habits of children should be targeted for cessation around 2-4 years old.
• 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. Parents and guardians need to take care of their own teeth to help protect and set an example for their children.
• 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 proper sized amount of toothpaste for the child’s age. 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. 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 adjacent to each other touch. 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.

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 dentist. Some common causes of toothache include: tooth fractures, tooth decay, tooth trauma, and wisdom teeth eruption (adolescence).

How you can help:

• Cleanse the area using warm water. Do not medicate or warm the affected tooth or adjacent gum area.
• Check for impacted food and remove it as necessary.
• Apply a cold compress to the affected area to reduce swelling.
• 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 will often 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:

• Recover the tooth. Do not touch the tooth roots! Handle the crown only.
• Rinse off dirt and debris with water without scrubbing or scraping the tooth.
• 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).
• Do not allow the tooth to dry during transportation. Moisture is critically important for reimplantation success.
• Visit the dentist – 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:

• Rinse the child’s mouth with cold water.
• Place ice packs around affected areas to reduce swelling.
• Offer Tylenol for pain relief.
• 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:

• Place a cold, moist compress on the affected area.
• Offer pain relief (for example, Children’s Tylenol).
• 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:

• Rinse the child’s mouth with warm water.
• Place a cold, moist compress on the affected area.
• Offer strong pain relief (for example, Children’s Tylenol).
• Pack the tooth with a biocompatible material.
• 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:

• Place a cold, moist compress on the affected area.
• Offer pain relief (for example, Children’s Tylenol).
• 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 lengthwise 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.

Dental radiographs, also known as dental X-rays, are important diagnostic tools in 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.

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 (TMD).

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.

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 teeth, and damaging oral habits.

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 or mixed 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.

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 sound, “no tears” 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?

It is important to remember that the order and timeline for the eruption of teeth is variable. Dentist look for symmetries in tooth eruption and give roughly 6 months plus or minus from the prescribed timeline.

As a general rule-of-thumb, the first teeth to emerge are the central incisors or the 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 also often the first teeth to be lost, usually between 6 and 7 years of age.

Next, the lateral incisors emerge on the upper and lower jaws at around 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 around 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 teeth then tend to emerge on the upper and lower jaws around 16-23 months. Canine teeth can be found next to the lateral incisors, and are lost during preadolescence around 10-12 years old. Finally, second molars complete the primary set on the lower and upper jaw by 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.

According to AAPD (American Academy of Pediatric Dentistry) guidelines, infants should initially visit the 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.
• Leave other children at home – Other children can distract the parent and cause the infant to fuss. Leaving other children at home (when possible) makes the first visit less stressful for all concerned.
• 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 purpose 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”:

• Dental staff will greet the children and parents.
• The infant/family health history will be reviewed (this may include questionnaires).
• The dentist will address parental questions and concerns.
• More questions will be asked, generally pertaining to the child’s oral habits, pacifier use, general development, tooth alignment, tooth development, and diet.
• The dentist will provide advice on good oral care, how to prevent oral injury, fluoride intake, and sippy cup use.
• The infant’s teeth will be examined. Generally, the dentist and parents 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.
• Good brushing and flossing demonstrations will be provided.
• 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.
• The dentist will detail which teeth may appear in the following months.
• The dentist will outline an appointment schedule and describe what will happen during the next appointment.

Fluorine, a natural element in the fluoride compound, has proven to be effective in minimizing 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. The dentist is able to monitor fluoride levels, and check that children are receiving the appropriate amount.

How can fluoride prevent tooth decay?

Fluoride fulfills two important dental functions. First, it helps to staunch bacteria that cause cavities, and second, it promotes the remineralization of tooth enamel that is stronger and less susceptible to acid attack.

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 between the ages of two and five years old should use a pea-sized amount of ADA-approved fluoridated toothpaste on a clean toothbrush twice each day. They should be encouraged to spit out any extra fluid after brushing. This part might take time, encouragement, and practice.

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 either be held on the teeth for several minutes in specialized trays or painted on with a brush.

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 food pyramid, children need vegetables, fruits, meat, grains, beans, 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 carbohydrates. 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 for prolonged periods, bacterial products begin to attack the soft tissue (gums) and even the underlying jawbone. Eventually, the teeth become prematurely loose or fall out, causing problems for emerging adult teeth – a condition known as childhood periodontal disease.

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 is 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, dentists may recommend a fluoride supplement 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), 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.