In the last decade, cosmetic dental services, including tooth whitening, has grown to a multi-billion dollar industry. More, now than ever, even in a down economy, people are still paying top dollar to improve their smiles. Some may argue that even more money is being spent on cosmetic teeth whitening than before, as an aid to increase competition in this already difficult job market.

There are many ways to whiten teeth and much of choosing depends on the person’s goals and personal preferences. Home whitening kits, both professional and over-the-counter can be successful, depending on the magnitude of white teeth a patient desires, as well as the initial color and yellowness of the teeth to be whitened. If teeth are extremely dark, then whitening of the teeth by the dentist may be necessary in order to achieve a patient’s cosmetic desires.

A visit to the dentist prior to starting any teeth whitening treatments is recommended, as there are situations that teeth whitening may be harmful to the teeth. In addition, you may actually save money by whitening in a way specific to your teeth rather than blindly spending money on things that may not work on you.

There are many over-the-counter tooth whitening kits available with many different types and concentration of bleach. Be sure to educate yourself on what you are buying in order to increase your chances of the whitest, brightest smile for the money!

The good news is that it could also be nothing. There are other causes of tooth pain which may be transient. If your dentist can find no apparent source for the pain, then they will likely search for other possible sources for it. Some of these may include simple things, such as night-time grinding (to be discussed later), food impacting in the gum, and irritation from flossing (this is not typical, since kids in the range usually refuse to floss)!

There are other reasons for tooth pain that can be a sign of something more serious. This is unusual, however, the possibility should not be overlooked. Your dentist should be aware of these and will likely evaluate for them if the problem continues with no apparent cause for the pain.

This is a question I get asked frequently and has an answer which provides a huge relief for many parents. In most cases, these yellower teeth are completely normal. It’s actually considered to be an optical illusion! You see, baby teeth, as mentioned earlier are actually nick-named “milk-teeth” because of their bright, white color. They are beautiful, delicate and oh-so adorable. Then, our permanent teeth make their appearance right beside those beauties. Permanent teeth are actually much yellower than baby teeth and often appear big and “gangly.” So, when sitting adjacent to something so spectacular such as baby teeth, they can appear downright ugly at times.

If you don’t make mention of it to your child, they often don’t even notice and therefore won’t become self conscious. The issue is that some people truly do have naturally darker teeth than others. Color and whiteness shades are highly variable and can also run in families. This is why whitening products have become so popular in our culture today. Once your child’s permanent teeth have all come in, re-evaluate the color then and see how they appear to you. My guess is that they will not appear as yellow/dark as they first did while next to the “milk-white” teeth. If they are, and if the child is self conscious, whitening toothpaste and possible whitening agents can be considered once the child is at the age appropriate time.

There is also another cause of yellow teeth in children which can be a quick fix-depending on your child. Often times the discoloration is caused by poor oral hygiene. If the child does an inadequate job at brushing, or refuses to brush regularly, a thick layer of yellow plaque builds up on the teeth. This can make teeth appear up to 3-4 shades darker than they actually are. So, look at your child’s teeth carefully. If you see a layer of “fuzzy” looking film that looks as if it could be scraped off, then you likely have your culprit.

There are generally not many foods or drinks that will cause staining at this age, unless you are allowing your child to have red wine or coffee! Iced or hot tea can also cause staining which is easily removed during regular dental check-ups. If your child has the dreaded “fuzzy’ layer and also drinks sodas frequently, the staining may be exaggerated. Smoking can also cause staining, but if your child is smoking at this age, then I suspect you have bigger worries than yellow teeth!

One last note to mention here. There are other causes of darker teeth and if you feel that these above are not the reasons for it, please see your dentist for an evaluation. There are multiple genetic disorders and diseases which can affect tooth color. These disorders can cause yellowing, but more importantly can affect the overall integrity of the teeth.

Examples of these disorders include but are not limited to: Amelogenesis Imperfecta and Dentinogenesis Imperfecta (each with sub-type categories). These disorders, cause defective enamel or other tooth tissues, can give a “flaking away” quality and appearance of tooth, rather than yellowing alone. There are ranging severities of the disorder and thus the appearance will vary from person to person. Though yellowing alone is uncommon in these disorders, it still can be the only obvious sign. When in doubt, check with your dentist, as these disorders need special attention in order to keep the teeth healthy. If the teeth appear red, green or brown or any other abnormal color, please see your dentist or physician immediately.

I need to address a widespread problem regarding bottles and sippy-cups. NEVER let your infant or toddler fall asleep with a bottle of milk or juice. I know from personal experience that lack of sleep can cause us to take desperate measures. One of these measures is propping or allowing a child to have a sippy-cup or bottle of milk or juice to help them fall asleep. This is the number one cause of severe tooth decay in children and its effects can be devastating. This situation is called “baby-bottle tooth decay” or “bottle rot.”

Image courtesy of Dr. Martin S. Spiller

Once the baby/child falls asleep, the milk and juice pools in the mouth and those cavity-causing bacteria commence their attack. It can decay a child’s teeth so quickly and so severely, that that the child can actually end up losing all or most of their baby teeth. This is especially troubling considering they don’t start getting their first adult teeth until around age six or seven!

 
This loss of teeth can lead to many disheartening situations, such as the child having to wear a partial or complete denture just to be able to eat. This is a very tough ordeal for a child to have to go through on many levels, including functionally, socially and psychologically. Not to mention the many extra trips to the dentist the child will have to endure throughout their childhood. So please try to remember to reserve those cups and bottles for mealtime only. You can see for yourself the devastating consequences that it can have.

Spaces between baby teeth are indeed normal as well as helpful. However, occasionally a child has a much larger than normal space between the upper two front teeth. This large space is what we call a “diastema,” which really just means a large space or gap. They are usually caused by the presence of a little extra muscle tissue between the underside of the top lip. This muscle attaches the lip to the gum tissue between the top two front teeth. We all have this muscle attachment, but occasionally the attachment may be a little excessive or attach a little further down toward/in between the teeth than usual. This slightly different attachment is sometimes just enough to keep the two front teeth from coming together. If not corrected, this attachment can stay present as an adult and may or may not cause other problems.

In general however, this is not something to be overly concerned about until the child is older. Your dentist may choose to have your child evaluated by the orthodontist, as sometimes the space will not close on its own. It is fairly easy to fix, sometimes requiring reshaping and or relocating of the attachment to a better cosmetic place with or without the help of orthodontics. Typically no treatment is performed to fix it until the child has all or almost all of their permanent teeth. If you and your child decide not to fix it, there is usually no problem associated with leaving it other than having the space there permanently. Occasionally if left alone, (this is usually when the problem is on the lower front teeth) the attachment can cause a defect in the bone and gums, causing a host of other problems. So, it is always best to have your dentist evaluate the area regularly during check-ups or if you have concerns about the space.

The great news is that your child is perfectly normal! Spaces between baby teeth are a great thing-especially for your wallet! As I said earlier, the body is amazing and the design of teeth is no exception to the rule. Those little gaps are the body’s pre-built mechanism to allow enough room for the larger, later erupting permanent teeth. Those spaces (called Leeway spaces) are your hopeful chance that you will avoid having to pay for braces later on.

The time to be more concerned is when your child has teeth like a supermodel. In other words, they have no spaces and perfect alignment. Beautiful as they may appear now, you are pretty much guaranteed that without any orthodontic treatment or strategic preplanning, your child will have crowded teeth as a teenager and adult. The good news is that dentistry has advanced in ways that now make it possible to understand the relationship between baby teeth, permanent teeth and skeletal growth in children. This knowledge now allows us to pre-plan in certain situations, possibly avoiding braces altogether. For further information, please refer to the “general questions” section of this book. More information will be found under the question: “How early should my child be placed in braces. How do I know if my child needs braces?”

This is a very common question, particularly with first-time parents.  One thing you must understand is that children are highly variable in their personalities, growth and especially their teeth.  There is no hard and fast rule as to when your child will get their first tooth, but rather general guidelines to refer to.  These relative times of tooth eruption can vary by many months, so when I say it is a general guideline I truly mean it.  Generally speaking, the first tooth will appear between 6 and 9 months of age.  My youngest son did not get his first tooth until he was 11 months old!  So don’t worry too much if your child is not following the guidelines exactly.

There are also extremes on the other end of the spectrum.  There are some infants that are actually born with a tooth or two.  These are called “natal teeth” and are a lot of fun for breastfeeding moms! It is usually only a concern  if they interfere with breastfeeding or if the teeth are loose and feared to be a choking hazard..  This is a situation that your pediatrician will discuss with you.

Here is a quick reference guide to follow and refers only to baby teeth:

6-8 months old

The first tooth usually appears and is almost always a lower front tooth (called lower central incisors)

8-12 months old

The top front teeth appear (called upper central incisors)

9-13 months old

Upper lateral incisors appear; these are the teeth immediately next to the already existing top teeth (lateral simply means “to the side of”)

10-16 months old

The lower lateral incisors appear; these are the teeth next to the now existing lower front teeth

13-19 months old

The first primary/baby molars appear on the top and bottom; They may appear simultaneously or at various times; There will be a large space between these molars and the other existing baby teeth.

16-22 months old

The canine teeth appear (also called cuspids or “fangs”) on the top and bottom and may appear simultaneously or separately.

This is perhaps the most commonly asked questions about children’s teeth. In fact, parents who have children in the 0-6 year old range often wonder if they even need to worry about their kid’s teeth at all. I would like to stress that this age range is one of THE MOST IMPORTANT times in the care and maintenance of your child’s teeth. Repeat after me: “This age range is one of THE MOST IMPORTANT times in the care and maintenance of my child’s teeth.” You are officially now more informed than 98% of the world.

I want to first dispel a major dental myth that we touched on briefly in the general questions section. You know, the one that says, “They’re just baby teeth, they are going to fall out anyway.” WRONG. Those cute, milk-white, little-bitty, ankle-biting pearly whites are the foundation that will determine whether or not you may have to pony-up $5000 for braces several years from now. Baby teeth are crucial in holding the space in the dental arch for the future permanent teeth. They predict and help guide the underlying permanent teeth into their future locations and thus will have a huge impact on both the appearance and functionality of adult teeth. Extracting them rather than filling them in many cases can cause mild to severe crowding, spacing and asymmetry of adult teeth that may not have otherwise occurred.

Without those baby teeth, we lose many opportunities to prevent later orthodontic problems. Not to mention when you extract teeth, adult or otherwise, you greatly affect the ability to chew. I think it is only fair that we allow our children to experience the delight of eating as we do, but children need to eat for nourishment to allow for proper growth. The ability to chew can limit what a child is able to eat and thus have effects on both their mental and physical development. So, we can see that in most cases it is better to try to save a baby tooth rather than extract it.

Too often parents consider baby teeth “disposable,” since they will fall out anyway. They are far from disposable and almost always benefit the child most by doing what it takes to save them. There are exceptions to this rule. For example, if a baby tooth has a cavity but no infection present, and the tooth is within 6 months of falling out, your dentist will probably recommend the baby tooth not be treated. This makes sense as it would be pointless to waste money on a tooth that will very soon come out on its own. In addition, removal of baby teeth can sometimes actually help prevent braces altogether. While braces may be unavoidable whether you maintain baby teeth or not, you’ll see that there are other extremely important reasons to keep baby teeth healthy. So, with this new paradigm shift in thought of caring for your child’s baby teeth, let’s go into more detail about these curious topics!

As both a dentist and a mommy, I get many questions about teething both at the office and in my own circle of friends. As a first time parent, many areas of parenting and childcare seem like such a mystery. We struggle our best by trial and error and constantly wonder if the question or problem really requires us to take a trip to the pediatrician. Do we want to shell out a co-pay or “wait it out” and see if the problem resolves on its own?

Well, my hope is that I can provide you with a little relief in this area child-rearing. Babies go through so many changes so quick, baby teething can bring about difficulties that feel like an eternity! Just when your bundle is finally sleeping through the night and you are settling in to the groove of being a new parent, the process throws you a new curve ball. Around 6-7 months, you may find your baby acquires some peculiar behavior and not all of it is enjoyable!

In general, the process of baby teeth begins at 3-4 months old, despite the fact that a tooth may not appear for several months after this. The baby teeth start their ascent into the mouth during this time and parents may notice some of the following behaviors in their infant: Excessive drooling, crankiness, biting and sticking objects in their mouths, coughing or colds, cheek or ear-pulling and unfortunately, night waking! While all of these can be signs baby teething, they can also be signs of other problems, so when in doubt, don’t be afraid to call your pediatrician-that’s what they are there for!

As these new baby teeth make their way in, they typically cause a lot of pressure and discomfort inside the gums. This process can cause crankiness and irritability and even cause baby to wake up at night in a crabby mood. It isn’t abnormal to have baby wake up crying or whimpering at night, only to attempt a bottle with no success. Sometimes they may even take the bottle only to fall right asleep without drinking much.

Babies often try to relieve this pressure during the day by chewing on any object they can fit in their mouth, including their hands. In addition, this grand appearance of teeth very much stimulates saliva flow, causing baby to drool excessively. All of these habits can cause other issues and strange behavior for baby. Excessive drooling during baby teething can cause a rash on the chin as well as stimulate the coughing and gagging reflex. They may also experience discomfort that is referred to the ears or cheeks.

The rashes are not usually a problem unless you find the rash to be causing pain, has open sores or bleeding. If this occurs, see your pediatrician for medicated creams to help heal the area and make baby comfortable again.

While ear and cheek pulling can be a sign of baby teething, it can also be a sign of an ear infection. My kids have had their fair share of ear infections and they can be such a frustrating experience. I have noticed ear and cheek pulling from baby teething to be pretty infrequent but not impossible. So, my suggestion would be that if you see this behavior, especially if accompanied with a fever, have your child evaluated by the pediatrician. Ear infections can be a very painful experience with possible complications and should not be “waited out.”

The drooling may also cause loose or runny bowel movements, but generally not diarrhea. If your baby has diarrhea lasting more than a day, call your pediatrician. While baby is trying to relieve pressure by putting object and fingers into their mouth, they unfortunately can be introducing unwanted germs into their bodies. So, you may notice and increase in colds or illnesses which may cause mild fevers or diarrhea. Fevers are not believed to be from teething directly, but are thought to be from the “bugs” that babies expose themselves to while going through the baby teething process.

So, how can you help your precious baby through this tough time which can last for months? Baby teething rings and toys or cold foods are a good start. Be sure that they are foods your baby is normally able to eat without choking! You can also gently massage the gums with your own fingers but please be sure to wash your hands first! Baby Orajel can be used, however, as a dentist I can tell you that unless you dry the area of gums completely before applying, it really will not work-you’ll only be providing bad taste and a numb tongue! So, if you can dry the area well, and your pediatrician has given you the recommendation to use it, then see if it works for your baby. Infant Tylenol or acetaminophen is another great option when baby is having a really difficult time during baby teething. However, before giving your baby any kind of medicine, always consult your pediatrician and be sure that you give the proper dosage for your child.

Children are not just little adults and so we can’t treat them as such. Baby teeth are shaped much different than adult teeth, which causes some need for modification when treating them. Because of the shape of baby teeth, we cannot place anything but a very small filling in them, otherwise the filling will break and a new cavity will be created.

The guidelines for treating baby teeth are that if a cavity is of moderate or larger size, a procedure called a “stainless steel crown” is done. This little, silver crown or “cap” is glued down over the existing tooth (after it is specially prepared for it). By having this fairly strong metal covering the entire surface of the tooth, the underlying tooth and filling is protected from breaking from the forces of chewing. As mentioned earlier, a filling or stainless steel crown is usually only needed on a baby tooth which is not due to fall out on its own any time soon. The dentist will evaluate the extent of root development on the underlying permanent tooth with an x-ray. This information, combined with the patient’s age, will be used to determine the approximate amount of time until the baby tooth would likely fall out on its own. If the dentist feels that it will be less than six to nine months, they may recommend no treatment of the tooth unless there is infection present. In this case, they may elect to proceed with the crown (and baby root canal) or simply extract the baby tooth.

Images courtesy of Dr. Martin S. Spiller

This stainless steel crown is similar to a crown or “cap” that an adult may have, except that it is cheaper and meant to come out when the baby tooth falls out. They are usually silver but occasionally for cosmetic reasons can be tooth-colored when needed on front teeth. If your child needs a crown on a baby tooth in the front, be sure to tell your dentist BEFORE the start of the procedure if you want it tooth-colored. They won’t always ask and once it is placed it is usually not easily removed.

 
A stainless steel crown may or may not also have a root canal done at the same time. Yes-baby teeth can have a root canals done on them. Once again though, the concept is different from an adult tooth. Your dentist may call the root canal by several names (each meaning something slightly different to the dentist but making no real difference to you as a parent). Some of those names you may hear are: root canal, pulpotomy, pulpectomy, pulpal debridement and pulp therapy. There are others, but these are the most commonly used.

A root canal in simple terms is the removal of nerve or pulp tissue from the inside of the tooth. It can be removed for many reasons, but for children it is usually done because of a cavity that extends into the pulp/nerve tissue or because of a dead nerve/pulp that is causing an abscess. Baby tooth root canals are different from adult teeth in a few ways. Unlike permanent teeth root canals, those performed on baby teeth do not usually have the rubberized material placed in the canals afterward. They usually only receive a sedative paste which hardens inside the tooth and keeps the infection away. This material is also easily deteriorated by the body as the roots of the baby teeth resorb away and prepare for eruption and loss. They are not as exact of a procedure as root canals on permanent teeth and take much less time. They are not painful and nowhere near as expensive.

So, we can see that sometimes both procedures may be done simultaneously or independently, depending on the child’s unique situation. Your dentist should discuss options with you and don’t be afraid to ask questions. You are your child’s advocate and so you should always attempt to keep yourself informed of any procedure being done

So, what happens if you don’t have the root canal or don’t treat the tooth in any way? Well, if you refuse treatment and also refuse then to have the baby tooth taken out, many things can happen, most of which are bad. The child can end up in the hospital with an infection, particularly if the child is diabetic. I have been unfortunate to have been witness to this and it is truly heartbreaking for me. Not only is this sad for the child, but it puts the dentist in an uncomfortable situation regarding appropriate care and treatment of a child. Proper authorities have to be notified if the child is put in danger. Thankfully this is not extremely common but it does occur.

If hospitalization does not occur, then the abscess will find a way to drain, usually by a small hole made in the gum to relieve pressure and drain puss-right into the mouth. This can cause bad breath and an upset stomach, not to mention it is just disgusting. The other major concern is that an infection left in the tooth can cause damage to the permanent tooth below the offending tooth. Damage may appear as a misshapen, malformed or discolored permanent tooth. It can also cause defects to the underlying developing jaw bone. The affected permanent tooth may then need treatment when the child is older to correct cosmetic problems which may arise as a result.