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Dental Care for Children

In this day and age, dental care for most children no longer involves extensive cavities and fillings, but rather it entails more prevention with occasional fillings and orthodontics. A major reason for this has been the impact fluoride has had on the ability of teeth to resist decay. This is not to say, however, that children can't have severe decay. On the contrary, with poor habits and improper care, children's teeth can deteriorate as much as they did fifty years ago.

Tooth decay is a progressive disease that results from the interaction of sugars in the diet with bacteria in the mouth. The bacteria use the sugar to create acid that removes minerals from the tooth surface. The weakened tooth surface is then susceptible to degradation or decay by the bacteria.

Your dental team, which includes the dentist, hygienist, and dental assistants, understand that regular maintenance is the best way to prevent decay and ensure a healthy smile for life. In addition, they have a whole host of tools and weapons to help restore, and maintain sound teeth and gums.

Pediatric Dental Emergencies

As children grow, learn to walk and play, and are developing, their coordination, sometimes injuries occur. They may fall and bump their teeth or be hit in the mouth. The following is a listing of the more common injuries and the steps that should be taken.

"Chipped" tooth

Teeth are composed of three layers: enamel (the outer surface), dentin (the middle layer), and pulp (the ‘nerve' of the tooth). If the ‘chip' or fracture only involves the enamel, usually the only treatment necessary is for the dentist to smooth the rough portion. If ‘looks' or esthetics are a concern, then a tooth colored filling may be bonded to the area. The tooth will then be monitored because sometimes the trauma has affected the pulp and symptoms may not be apparent for some time -- perhaps years.

If the tooth has broken into the second layer, the dentin, the tooth will usually be sensitive to hot, cold or the movement of air (as during breathing). This is because the dentin has microscopic tubules that reach all the way to the pulp. For this, the dentist may opt to place a medicated filling in an attempt to calm the pulp, then restore the tooth later. Another option is to place a tooth colored filling immediately. Or finally, the dentist may decide that a medicated liner under a tooth colored filling is the best treatment. This decision is based on the extent of damage done to the tooth. Again the tooth will be monitored for pulpal changes.

If the fracture goes all the way to the pulp, and is a small exposure, the dentist may opt to place a medicated filling, and then see how the tooth responds. If the tooth shows no pulpal changes, then a conventional filling is placed. If pulpal changes develop, or there is a large exposure of the pulp to begin with, then the dentist will need to access other factors beside the damage: is the tooth a ‘baby' (primary or deciduous) tooth or permanent (adult). If it is a primary tooth, then it is necessary to determine the time before the tooth is lost. If the tooth is a permanent, the dentist needs to determine how fully formed is the root.

For a primary tooth that is due to come out soon anyway, the dentist may recommend extraction. When the tooth is supposed to be in the mouth for a few more years, the dentist will try to save the tooth by performing a pulpotomy (remove some of the exposed pulp, then place a medicated filling) or a pulpectomy (remove all the pulp and fill with a resorbable material. The resorbable material is used so the permanent tooth will be able to erupt normally). The decision to remove all or some of the pulp depends on the extent of damage to the tooth.

Some people may ask "Why go through all this trouble for a baby tooth when it's just going to fall out anyway?" Primary teeth serve an important function in the development of speech, chewing, and swallowing and also serve as space holders for the permanent teeth. The effort of saving a baby tooth now may save a much bigger effort to correct the problem later.

If the fractured tooth is a permanent tooth, a large portion of the pulp is exposed, and the root is fully developed, usually a conventional root canal will be done. If the root is not fully developed, it has an ‘open apex'. With fully formed roots, the canal that contains the pulp narrows at the end, to an opening smaller than the head of a pin. With an open apex this constriction has not occurred so a conventional root canal cannot be done. If the apex is open, and a large fracture occurred, the dentist will remove the pulp and will treat the canal with a material that will try to have the body form a calcified bridge across the apex, which in effect closes the canal. This process may take many months and often requires follow up visits to place fresh material in the canal. Once the bridge forms, a conventional root canal is done for the best long term success. Remember if only a small area of the pulp was exposed, the dentist would place a medicated filling and follow the tooth. In this case, if the tooth had an open apex, the pulp may survive long enough to close the apex itself.

With most cases of tooth fracture, the dentist will need to take radiographs (xray films) of the tooth for diagnosis. In some cases, it may be necessary to make a radiograph of the soft tissue (like the tongue or lip) to make sure there are no fragments of tooth lodged there.

Tooth is loosened or moved

For this condition it is important that your child see the dentist as soon as possible, usually the same day, because if the tooth needs to be realigned, it's easier to do before it heals into its new location. The dentist will take a radiograph (xray film) to determine if the tooth is fractured and it's location relative to other anatomic structures. If the tooth was pushed into its socket, usually the tooth is just periodically evaluated as most teeth will reerrupt into their proper position. If the tooth was moved front, back or to the side, the dentist may bring it back into place with digital pressure (the force in the fingers). Later orthodontic movement may be necessary.

The teeth are then monitored for pulpal changes that may require a pulpectomy or conventional root canal (see previous section on chipped teeth). The teeth may discolor black, dark brown or gray as the blood cells in the tooth break down -- just like a bruise on the skin. In primary teeth, this may lighten because the circulation can come in to clear away these breakdown products. In permanent teeth, usually the tooth will require a root canal. Primary teeth that are dark and causing pain will also need the removal of the pulp. The teeth may also become more yellow over the course of time, because the pulp is laying down more dentin as a result of the trauma. The tooth appears more yellow because the tooth becomes denser and less light can pass through it. This is usually not a concern with primary teeth. However, with permanent teeth a root canal may be indicated not only to improve the look but also to clean out the canal before it calcifies. When a canal calcifies, some nerve fibers may still persist that can ‘flare up' in the future.

All teeth should be monitored and reexamined.

Tooth knocked out (Avulsed)

First, try to find the tooth (or teeth). Handle it by the crown of the tooth (the portion of the tooth that shows when someone smiles). Do not handle the root. Do not brush or wash the tooth because it will strip off vital cells. Keep the tooth moist by immediately placing it in milk, clean water, special solutions for avulsed teeth (these can be purchase at most pharmacies and should be kept with a first aid kit), or, if the child is old enough, have them hold it in their mouth, tucked into their cheek. If you are confident enough, know it's a permanent tooth and there is not a lot of other trauma to the area, you can stick it back in the socket it came from -- but do not force it. Go to the dentist immediately! The longer the tooth is out of it proper place, the less chance of successfully replanting it. At the dental office the dentist will replant the tooth and splint it to stabilize it. Also they will take radiographs (X-ray films) to determine the extent of damage. Sometimes the bone can be fractured and/or splinters of tooth can lodge in soft tissues. The tooth will be followed for the success of re-implantation or possibility of future root canal.

Sometimes if the tooth has been out of the mouth for many hours the dentist will perform the root canal first then replant the tooth. Again, the best chance of successful re-implantation is when the tooth is back in its socket as soon as possible.

When primary teeth are knocked out they are not replanted. This could cause damage to the developing permanent tooth. Still, the child should have a dental visit ASAP because there may be other damage that is not immediately obvious. The tooth (or teeth) should be brought to the dental office because it can provide the dentist with important clues; for example, did the whole tooth fall out or is there some piece somewhere that must be removed. If the missing tooth (or teeth) is of an esthetic or speech concern, an appliance can be made after any swelling goes down, to replace the tooth (or teeth).

Some general first aids points to remember because usually more than just the teeth are hurt:

Direct pressure to slow or stop bleeding.

Ice to reduce swelling.

With any head injury if the child is disorientated, pupils are of uneven size,

unconscious for any length of time, or is having trouble breathing, they need emergency medical care immediately .

Sealants

Sealants are a clear or white plastic material flowed onto tooth surfaces to fill deep grooves and pits. The biting surface of back teeth is the area benefiting most from sealants. The pits and grooves are areas where toothbrush bristles cannot clean and fluoride cannot access. As a result, bacteria tend to accumulate there and cause decay. Sealants function to fill in any crevices, thereby preventing tooth decay. If utilized, along with proper homecare, sealants significantly increase the chance of your child becoming cavity free for life

What are sealants and why are they important?

Permanent molars usually have much deeper grooves than on primary molars. These deep grooves usually end in microscopic fissures that cannot be properly cleaned. Sealants are a flowable composite material, similar to the material used for white or bonded fillings. This material fills in these grooves to keep out the bacteria that cause tooth decay.

At the dentist office, the tooth is first cleaned of any food debris, usually with pumice. Then the tooth is isolated using a rubber dam or cotton rolls. The tooth is then acid etched for about fifteen seconds. This prepares the surface of the tooth for sealant material. The tooth is then thoroughly rinsed.. There might be a sour taste, similar to a strong lemon, from the etch if the cotton isolation is used. The tooth is then dried completely as any water will weaken the bond of the sealant to the tooth. The sealant is then flowed into the grooves and a very bright blue light is used on the tooth to harden the sealant. The bite or occlusion is then checked to make sure that the sealant is not ‘high'. The entire procedure for one tooth, on a cooperative child, takes about five to ten minutes.

Sealants are usually done when the permanent molar has erupted enough to be properly isolated, usually around the age of six. The next set of four molars arrive around the age of twelve. Bicuspid teeth may also need sealants. These eight teeth arrive between the ages of eleven to fifteen. Sealants may need to be reapplied after a few years as they will wear. Sealants are only placed in the pits and fissures of the tooth because they do not adhere well to the smooth surfaces of the tooth.

Along with fluoride and good home care, sealants are another reason that many children have few or no cavities.

What can I do to prepare my child for their first appointment?

Children are usually apprehensive about the unknown. So tell them that the dentist will count their teeth and make sure those teeth are healthy and strong. The dentist will also clean their teeth with a special electronic toothbrush that sometimes can feel ‘tickly’. Don’t overwhelm them with a lot of details because it can be too much for them to comprehend at once. Also don’t tell them what’s not going to happen i.e. "It’s not going to hurt." Children will focus on the word hurt and can become anxious. Plus, everyone has different perceptions of pain. A child may think that the rotating rubber prophy cup (the ‘electric toothbrush’) ‘hurts’ because they have no other label to define this new feeling. The child may be uncomfortable and if you said, "It’s not going to hurt", then you lose credibility.

There are children’s books about the dentist that are nice to read so they can know more about what happens at a dental office. Most are available at your local library.

What are good snacks for my child?

To answer this properly it is first important to note that cavity formation is directly related to the time the teeth are exposed to the sugar, not the amount of sugar. And secondly, all foods contain some sugars. So therefore you don't want to have snacks that are sticky and retentive like caramels and jellybeans. Dried fruit also can be very sticky as well. Plus, with something that is in small bits, like raisins, kids usually eat a few, then play, and then eat some more so the exposure time is increased. The ‘best' snacks are foods like nuts, fresh vegetables, cheeses, and fruit. That's not to say that kids shouldn't ever eat ‘sweets'. When they do eat them, it should be after a meal when the saliva is active, and brush afterwards. This limits the exposure time and limits chance of decay.

Why is fluoride important to my child?

Fluoride acts on teeth in two ways: 1) it helps the teeth already in the mouth by strengthening tooth structure and limiting bacterial growth, 2) fluoride is incorporated into the developing teeth to make them less prone to decay. Fluoride that is found in toothpaste, rinses and gels applied at the dental office work on teeth in the mouth while fluoride added to town water supplies and in prescription tablets help the developing teeth. Fluoride tablets are only prescribed by the pediatrician or dentist when the child in not receiving any other ingested fluoride. If too much fluoride is taken internally it can cause the permanent teeth to have mottled appearance. This is also the reason why only a small amount of toothpaste should be used when brushing children's teeth. With the low dose of fluoride added to the water supply, the teeth get the maximum benefit with the lowest (almost negligible) chance of altering the appearance of the teeth.

How do I know if my child needs braces?

Part of your child's dental examination is an evaluation of the developing bite relationship. Large discrepancies may need to be corrected early for a more normal development. This early intervention can also decrease the amount of orthodontic work needed later. Smaller ‘problems' may or may not need early treatment. Your dentist may recommend an orthodontic evaluation to determine what is best for your child's specific case. To help with diagnosis and to keep a record of growth, the orthodontist may take models, radiographs (xray films) and photographs of your child.

Is thumb sucking bad for my child’s teeth?

Thumb sucking (or finger sucking or pacifiers) become a problem dentally when it alters the occlusion (the child’s ‘bite’) and exacerbates an existing malocclusion or speech problem. This is an occasion when your child’s dentist may refer them for orthodontic evaluation. If it has been determined that the habit is affecting the child’s development, there are several options to help the child stop. First, the child must see the need for stopping. Remember the adage: ‘You can lead a horse to water, but you can’t make it drink. The trick is to make it thirsty.’ A good start is the child realizing that the habit is altering their bite. Simply showing the child their smile and pointing out how the thumb (or whatever) is moving their teeth or keeping them from growing into the proper spaces. Don’t terrorize them with the treat of braces or other negative methods because this may cause problems later.

The next step is to start limiting where the child is allowed to suck their thumb. For instance, the first week no thumb sucking in the car, the next week add no thumb sucking while watching television. Let the child help choose the area where the habit is eliminated so they feel some control.

With young children and pacifiers the first thing to do is to get rid of all but one pacifier. Then just let that one start to wear out so it becomes unappealing to the child. You can help this process along by placing it in hot water so the nipple gets gummy. Also eliminate the pacifier when the child is distracted with something else. A child who is busy playing may be too busy to miss their pacifier.

What is "baby bottle decay"?

When children are put to bed with a bottle, the sugar that occurs naturally in milk or juice is allowed to sit on the teeth all night. This causes rapid decay of the upper anterior teeth and the molars, so much so that these teeth can break off at the gumline and appear as black stumps. In extreme cases, these broken down teeth must be extracted so they don't damage the permanent teeth. If children have bottles at bedtime, they should only have water in them. If you suspect that your child has this condition, see your dentist.


How can I clean my baby's teeth?

With very small children a washcloth or piece of gauze may be used to remove the sticky plaque that coats the teeth. Even before the child has teeth, you can wipe out their mouth so they get used to the feeling of doing that, and get used to the feeling of a clean mouth. This makes for an easier introduction to toothbrushing later.

When children won't brush - some hints for parents

Toothbrushing is necessary for good dental health, so it's important to establish good habits early. This is sometimes difficult, but you need to be persistent. It can be very frustrating to a parent when the child just will not brush. The following are some hints that may help.

Toothbrushing should be a part of the daily routine. Children should brush in the morning, after breakfast, and at night, after any snacks or bedtime drinks. Kids will start to realize that brushing is an everyday event, like getting dressed, and their reluctance will become less. Also, children learn good hygiene habits by watching their parents. So let them see that you brush (and floss).

Children may not know why they have to brush. Explain to them that brushing is important because it removes the old food and ‘mouth germs' or ‘cavity bugs' (meaning the bacteria), and explain that if these things are justify on the teeth, holes or cavities can result. You have to explain using works your child understands, and that are geared to their age group.

Children seven and under need help brushing because they have not yet developed the manual dexterity to brush effectively. The best way to help is to ‘take turns': the adult brushes first, without toothpaste to remove all the debris, then allows the child to brush with the toothpaste to spread around the fluoride. Not only do they get ‘their turn' but they also learn responsibility for their own hygiene. When you brush your child's teeth, the best way to position yourself is to sit down and have the child stand in front of you, facing away. Now lean the child back onto one arm, and brush with the other. This gives the child a comfortable place to rest their head, and they are less able to pull their head away from you. In addition, you can slide one finger from you cradling arm to retract the cheek. Be careful not to be bitten. By using no toothpaste when you brush, you can see more clearly without the bubbles and your child will not have to spit so you can brush longer.

Although it can be frustrating, you have to be persistent and consistent about your child's brushing. You can ask your dentist to reiterate the importance of brushing to your child and ask for their personal recommendations.



 

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