Young children do not have the manual dexterity to brush and floss their teeth on their own. Therefore, you must take a toothbrush to their teeth at least twice a day. When my kids were small, I would sit down in the bathroom and have them lay their heads back into my lap. That gave me plenty of access to all of their teeth. It would only take a half a minute to scrub their pearly whites. As they got older, I could have them tilt their heads back from the standing position. Once the last set of baby molars come in, you must start flossing their teeth. You only need to floss between the molars since those areas are prone to decay and will be around for number of years. You can use regular floss or you can use a floss-pick, the little “U”-shaped device that holds a short piece of floss taut and has a handle to hold on to. For children, it is best to get the floss-pick that have safety handles so that there are no sharp ends to injure your child.
Teething is when teeth are erupting through the gums and the symptoms associated with it. There are many myths on all of the maladies that teething will cause, most being totally untrue. Surely the teething infant can get a little fussy because the gums do get sore, but it doesn’t cause fever, nasal congestion, diarrhea, etc. It is best to avoid all of the drug store teething preparations. Local anesthetics should not be used because they have too much difficulty with proper dosing. Too much benzocaine or lidocaine can cause seizures and in severe cases, death. The best thing to use for teething discomfort is a rubber teething ring that can be place in the refrigerator. It is thought that cool pressure placed over the gums can be soothing. In cases where an analgesic is needed, be certain to carefully follow the dosing instructions since infants are tiny and susceptible to overdosing.
A very common question is “What is the best age to bring my child for their first dental visit?” The American Academy of Pediatric Dentistry recommends at the appearance of the first baby tooth. Although parents are welcome to bring their children in at that time, in the absence of any obvious decay, we usually start seeing children around their third birthday. Most children are able to sit in the dental chair and get their teeth cleaned and checked at that age. For those who are too fearful, we do a “knee to knee” exam. A parent holds the child in their lap facing them. The parent has the child’s legs straddling their lap, and holds on to their hands. The seated parent faces the seated dentist “knee to knee” and lowers the child so that their head in in the dentist’s lap. Since the child is facing the parent, they remain calmer and are safe from sharp objects since the parent is holding their hands. This way, the dentist can safely examine the child’s mouth, the child does not get out of what they thought would be an unpleasant situation by acting out, and still feels comfortable by being with the parent.
Another common situation where a permanent tooth is not in its normal path of eruption is when the first molars (six year molars) are attempting to come in too far forward thus resorbing the roots of the baby tooth that is ahead of it. If this situation is allowed to continue, then it will cause the baby tooth to be lost prematurely. The offending permanent molar will then erupt too far forward, thus leaving no room for the bicuspid to erupt later. I have found that by pushing the molar back before the baby tooth is lost, then the baby tooth can be retained until its normal time to come out. The procedure is call distalization. I connect orthodontic bands on a couple of molar teeth and connect them to a spring. I then bond a hook on the chewing surface of the offending tooth and engage the spring. This pushes the tooth back into its normal position. I remove the spring and allow the tooth to erupt normally. The process takes from two to four months.
Ectopic eruption is where a permanent tooth is in an eruptive path that is out of line with the norm. The most common example is that of wisdom teeth. Since there is not very much room for them to come in normally, it is extremely common for the wisdom teeth to be directed in all sorts of directions. The usual corrective procedure for that is removal of the wisdom teeth. A common occurrence of ectopic eruption is when the permanent lower incisors erupt too far on the tongue side. It kind of looks like shark teeth with them in two little rows. I have had many a frantic patient rush their child into my office to show me that problem. I have found that if the baby teeth are extremely mobile, they can be allowed to come out naturally. However, if not, I recommend extracting the offending baby tooth or teeth. By doing that at the proper time, the tongue will push the permanent teeth forward into their natural place without the need for expensive orthodontic treatment.
An orthodontic evaluation during routine dental examination is very important for children. In many cases, early treatment of orthodontic problems can make subsequent phases much easier, less expensive, or may even eliminate the need for further treatment. Many parents think that one has to wait until all of the baby teeth come out and the permanent teeth are in before starting orthodontic treatment, however, many problems – such as lack of space or crossbites – can be corrected early while there are still baby teeth present. The results can be much more stable when done early. The muscle tone of the lips, cheeks, and tongue are still in a states of flux in a young child. The muscle tone usually doesn’t become set for life until all of the permanent teeth come in. That gives a little window of time that the size of the jaw can be changed and the result will be relatively stable, whereas, doing it later in will have a high rate of relapse.
When a nerve has been exposed on a baby tooth, that usually means that there was a sizable cavity. Since baby teeth are so small, large cavities can make it difficult to retain fillings for any length of time. Therefore, it is best to place crowns over those type of teeth. Since baby teeth will be coming out in a few years, it is best to not put an expensive porcelain crown on it. The recommended procedure is to place a crown made of stainless steel.
These crowns come pre-formed so they do not have to be custom made. They come in various sizes. The dentist will remove the outer layer of the tooth, then try on different sizes until one is found that fits. The stainless steel is thin enough that it can be modified with special pliers if needed to get a better fit. The crown is then cemented into place with the same cement used for adult crowns. Although this technique is not ideal for long term, it works well in the interim for baby teeth and keeps the costs down significantly.
When a cavity has extended into the nerve of a baby tooth and the nerve is still healthy, it is best to save the tooth. When a nerve is exposed in an adult tooth, normally a root canal would be performed. However, since a baby tooth will only be in a child’s mouth for a few years, there is no need to do an expensive treatment like a root canal. A procedure called a vital pulpotomy is recommended. In a pulpotomy, the top portion of the nerve is removed leaving only the remnants inside the roots behind. The remaining nerve stump is treated with a medication to stop the bleeding. The most commonly used medicament is formocresol, although ferric sulfate, calcium hydroxide, or mineral trioxide aggregate have also been tried with varying success. Formocresol will not only stop any bleeding, but also mummifies the tissue effectively sterilizing it and keeping the underlying nerve alive and vital. The area is then covered with a base such as zinc oxide and eugenol, calcium hydroxide, or glass ionomer.
In children, cavities tend to grow much quicker than they do in adults. This may be due to their immature immune systems not being able to keep the cavity producing germs at bay, the tendency toward a higher sugar content in their diet, and their lack of manual dexterity to properly clean their teeth. With the relatively rapid expansion of decay coupled with the small size of the baby teeth, it is not uncommon to see a cavity reach all of the way to the nerve. Once that happens, a decision has to be made on whether to restore the tooth or to extract it. If the tooth still has a healthy nerve, then it is usually best to save the tooth if it is restorable. Front teeth aren’t as important in maintaining space, so they can be removed without regret other than the cosmetic aspect. If the tooth does have to be extracted and it is a back baby tooth and it will still be more than a year before the permanent tooth is expected to erupt, then a space maintainer must be cemented in place to keep the permanent teeth from shifting.
Once a cavity has been cleaned out and the tooth prepared to accept the filling, now we have to decide what to fill it with. The two major choices are amalgam and composite. Amalgam is the material that has been used for over a century. It is an alloy of silver and mercury. Over the years, there has been a lot of negative media coverage on the use of mercury, however, once the silver and mercury are mixed together, the alloy becomes inert.
Since the material has been used since the 1800s and has been no population study that has shown any ill effects of using the mercury containing fillings, you need not worry if your dentist recommends using amalgam to fill your child’s teeth. In our office, we give the parent the choice of either the amalgam or tooth-colored filling material. The newer composite fillings have been shown to have a life span long enough to have the baby tooth come out naturally and are therefore a fine alternative.