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.

Alright, let’s face it-most adults do a poor job of brushing their teeth on their own. So, it should be no surprise that most kids do an even worse job (including my own). My oldest boy is nine and highly intelligent. However, if I let him brush on his own and then check after him, you would swear that he just ate a plaque sandwich right before I looked. Disgusting, I know, but incredibly true.

Now, we of course have to let our children acquire their independence whether we like it or not. Trust me, if I had it my way, I would drive him everywhere and keep his curfew at 10 PM until he was 30. But I can’t, so I have to go with the flow. With brushing, this too is the road I must take. You need to allow them the independence to brush on their own, even from a young age (at 2 or 3 years old). However, like all parents, we must be undercover detectives and be sure they are doing an okay job. So, I will often check after brushing and give helpful hints on areas they may have missed.

Another completely covert method of checking up to ensure adequate brushing is the use of those plaque dyes made just for kids. They swish it in their mouth for a few seconds (the child must be old enough to spit it out to use it) and it will stain any plaque on their teeth. The child will think this is so cool to see and then has the job of removing all the colorful stain. You can obtain these dyes in a few different ways: First, you can ask your dentist if they can give you the little pink or blue tablets (chewable) that stain their plaque (called disclosing tablets). Then, your child just chews them up, spits out the excess and voila-a beautiful bounty of stained bacteria to brush off! Second, you can use a plaque staining rinse for children (i.e. Agent Cool Blue by Listerine). Then they simply rinse instead of chew. I personally prefer the tablets, as they work much better and stain much brighter. They can be harder to find over the counter however.

Speaking of stain-those little tablets and swishes are also fabulous as staining lots of other items, so you may want to supervise the process! As mentioned earlier, the child should be old enough to rinse and spit the mouthwash out without swallowing to avoid any potential toxicity. As a side note, teenagers seem to be the worst at brushing. So be prepared for some dental challenges. Don’t fret too much, however, for us dentists are fantastic at giving lectures and guilt-trips to teens, especially in front of their parents. You can use this tactic however you choose. Parental threats to teenagers have ranged from taking away TV and video games, all the way to making the child help pay for any cavities found at the next appointment!

Unfortunately,  black spots on teeth are usually the sign of a problem.  The most common cause of black spots on both baby and permanent teeth are cavities. In the early stage of cavity development, they appear white or yellowish and are “chalky” looking.  This description is given so because the consistency of the cavity is such that it feels like chalk if you were to touch it.  It literally will “flake” away if touched with a dental instrument.  If the cavity continues to progress, it will go through several other color and consistency changes which typically yield an end-result of the black color.  Sometimes they may only appear dark brown, as color can vary between individuals.

There may or may not be any pain at all associated with the cavity.  Frequently when I find cavities the first thing that people will say to me is, “But Doc, it doesn’t hurt.”  My next response is almost always, “Cancer doesn’t usually hurt either-until it has progressed too far.”  Tough analogy, I know but very true.  If a cavity gets to the point where it hurts or starts that “twinging” feeling, it usually means that it is pretty large already.  This may or may not mean that the tooth needs a root canal.  But first, let’s describe the cavity process and how it effects teeth.

A cavity is simply a bacterial  infection in the tooth.  These bacteria use the sugar in our foods to “eat” and thrive.  As they “digest” these sugars, the bacteria secrete a strong acid as a waste product.  This strong acid decomposes healthy tooth structure (called enamel and dentin, which are non-living substances) and turns it soft and mushy.  If this process continues, it eventually decomposes close to or into the nerve chamber of the tooth (also called the pulp chamber or nerve).

Once these bacteria are exposed to the living tooth nerve tissue, it infects the pulp chamber and causes the nerve and blood vessels in the tooth to die.  The process is usually quite painful in its final dramatic death scene, but may eventually stop hurting.  Loss of pain sensation is because the infection likely found a way to escape the highly dense tooth compartment (the tooth root system and surrounding bone).

Here’s where it gets really gross.  This release of pressure and pain is because the pus/infection found a way to drain into the mouth.  Often you can’t see where it is draining, but sometimes you can.  It is usually in the form of a little “knot”  or bump on the gum next to the tooth which expels puss through a tiny little opening.   This secretion of puss releases pressure build up from the infection and then suddenly you feel much better.  At least for awhile.  If left long, the infection will come back much worse, usually with outward and swelling and a whole lot of pain!

Once this start of this entire process begins, it is irreversible and the dead nerve tissue has to be removed or a massive infection can occur.  This infection can stay localized within the jaw, but can also become life-threatening if the infection enters the blood stream and goes through the rest of the body.  This process to remove the infection is called a root canal and the treatment and type of root canal depends on whether the tooth is a baby tooth or a permanent tooth.  We’ll address root canals of both kinds in a later section.

Trust me when I tell you that root canals have gotten a bad reputation.  Yes they are expensive (can range from $600-$1000 each), so preventing them is better than having to pay for one.  However, the reputation they have received for being horribly painful is a myth.  Normally root canals are only painful if you wait to go to the dentist until your infection/abscess is very bad (swollen and/or painful to the point of tears).  The reason for this is that the localized infection actually counteracts the anesthetic used to put the tooth to sleep, allowing the root canal procedure to be felt.  Very painful indeed.

So what exactly is a root canal?  Well, simply put, a root canal is the removal of the dead or dying nerve tissue within the tooth, followed by a cleansing of the nerve canals to remove as much of the bacteria as possible.  Then the empty, clean nerve canals are filled with a special sterile rubber material which seals the canals to prevent more bacteria from entering the tooth.  It is generally not painful at all, and one of the dental procedures I consider to be the most boring and relaxing of all (for both the patient and the dentist).  The key here again is to NOT wait until it starts to hurt.  If you or your child feels something strange going on in a tooth, it is always better to have it looked at and be on the “safe-side.”

While the black spots are usually cavities, this whole root canal process is meant to describe what happens in a permanent tooth.  Baby teeth can also get these same types of cavities, but the treatment is slightly different for both the cavity and the root canal (if needed).  The discussion on treatment of cavities and root canals in baby teeth will be discussed further in the next few questions.

There are other causes for black spots, but they are less common and include the following: damage during tooth development, underlying systemic disorders and excessive amounts of fluoride (usually occurs when given excessive fluoride supplement).  As always, take your child to the dentist for an evaluation immediately if you see black or white spots on their teeth.

Sealants are a very popular procedures these days and for good reason.  Sealants are different from a regular filling in several ways.  First and foremost, a sealant is placed as a preventative measure on a tooth in order to help protect it from getting a cavity in the future.  Sealants are usually only placed on permanent molars and usually only if the teeth show deep grooves which appear susceptible to tooth decay.  A “filling” is done because a tooth already has existing decay which needs to be removed, followed by “filling” the hole back in.

Sealants material is just slightly thicker than finger nail polish and is either clear or white and isn’t strong enough to be used for “filling”.  The sealant material bonds to the tooth’s deep grooves and coats them with an almost invisible layer.  The sealant, once placed, is hard and impenetrable and  therefore keeps food and cavity-causing bacteria from accumulating in the grooves of the tooth.  The theory is then that the tooth will be less susceptible to decay because both the bacteria and their food source for causing decay cannot easily stay on the tooth without the presence of these deep grooves to hang out in.  This would then lessen the likelihood that the bacteria could cause a cavity.

A  “filling’s”  composition is similar to the sealant material except that it contains very hard glass crystal particles.  These glass particles make it much stronger and less prone to wear and breakage than a sealant.

This property is not necessary with a sealant, as you are generally not removing any tooth structure (creating the hole from removing decay).  You are simply laying a protective coating down on the tooth.   The sealant material should NEVER be used alone as a filling and if you notice this during your child’s visit, be sure to ask why.  Sometimes you will find that your dentist places sealant material over the top of a new filling.  This is actually a good thing and is done to help protect any grooves on the tooth that were not affected by decay.

Sealants are placed by cleaning the grooves of the teeth to be treated with a lightly abrasive cleansing paste. The teeth are then prepared by placing a special acidic cleaner, which will be rinsed off and dried.  The sealant material is then placed on the tooth, followed by a special dental light, used to harden the material.  Once placed, the sealant is almost invisible or just barely white.

The child does not need to be numbed for the procedure and is generally very quickly finished, depending on the behavior and opening ability of the child.  The most challenging part of the procedure for both  the child and the dentist, is that the teeth have to stay completely dry the entire time.  If the teeth become contaminated with saliva at all, the sealant material will not stay long-term.  You can only imagine how tricky this can be on squirmy little ones who also happen to have saliva that flows like a fountain!  You think getting them to eat vegetables is tricky-try this out and you’ll feel honored to be the vegetable monitor!

My personal philosophy on sealants is this:  Sealants are a fantastic preventative tool if they are done correctly.  Though it is a simple procedure, it is very technique sensitive and requires precision work for it have a good outcome.  Unfortunately, there are two mistakes I have seen which can not only cause the sealant to fail, but ultimately lead to a cavity, which is the exact thing we are trying to prevent!

Dental assistants and dental hygienists in some states are legally allowed to place sealants without help from the dentist, provided the dentist authorizes it and is they are present in the building at the time.  Most assistants and hygienists are more than capable of placing them correctly.  However, as a dentist who works on children frequently (including my own), I will tell you that those kids are big wigglers!  I have rarely treated a child (unless much older) that can sit still and hold their mouth open long enough to do the procedure adequately all by myself.  So, if I am the dentist, the “top dog” so to speak,  and I am telling you it is already tough to do well with two people helping, then how good will the sealants be if someone with less experience and training are placing them alone?

It is definitely a two-man job most of the time. A second person is really necessary to hand the other person materials/instruments, suction the saliva and rinse the cleanser while the other is soothing the child, keeping the mouth open and placing the sealant, all in a matter of seconds.              If you are a parent of a child in this age range, you can only imagine the difficulty of this, all the while not getting a single drop of saliva on the tooth before the sealant hardens up.  In fact, children’s saliva flow increases significantly when dental procedures are being performed, adding even more difficulty to the process!

In addition, placement of too much sealant during this chaotic process can also have the same poor outcome.  Sealant material becomes very weak when thick, and is then more prone to fracture.  I frequently see new decay around sealants that have fractured because of excessive thickness of the material.  So, if you look in your child’s mouth and can see the material easily after the sealants are placed, there may be too much material placed.  This is not always the case, as sealant material color can vary from manufacturer to manufacturer.  However,  the sealant should definitely appear confluent with the anatomy of the grooves of the tooth rather than a “blob” of white stuff in the middle of the tooth.

Contamination with saliva and sealant fracture can actually lead to a cavity faster than if not placed at all.  However, a sealant placed properly can have dramatic results in preventing cavities for years!  Most dental offices do a great job in their placement, but at least now you are informed of the process and if something doesn’t seem right to you, then always ask!  All if this being said, I am not saying to blame your dentist/hygienist if the sealant fractures or gets a cavity around it.  This can still happen even if the sealant was placed absolutely perfect.  But minimizing these technique errors can certainly raise the chances of having a successful sealant.

So, if it were me at the dentist with my child getting sealants, I would always request two people to help during their placement.  This may agitate the staff a little, because they probably hadn’t planned for this and may cause them to run behind schedule.  But, rest assured, they will get over it and you will get a better sealant!   If they are still sour about the request or refuse it altogether, then it may not be the place you want to go for dental care!  You can blame it on me if you like, I don’t mind! I would rather your child not receive a lousy sealant!

This is a very common question from parents.   Most often, if a child’s breath still smells after brushing, it is because they are not brushing their tongue.  The tongue is a haven for bacteria and makes a nice “home” for them to grow and reproduce.  These normal occurring bacteria, when allowed to grow excessively, can cause a quite foul smelling aroma if not brushed away.  This can happen to adults as well, and so as part of your brushing routine you should include a thorough scrubbing of the entire tongue.  Your child’s tongue should appear pink, including at the back.  If they have a yellow or whitish-looking  coating, they likely are not brushing their tongue.

This could also, however, be “thrush,” a fungal overgrowth common in babies, but less common in toddlers.  So, if they brush their tongue well and it still does not come off, consider a quick trip to  the dentist for an evaluation.   Thrush is easily treated but if left untreated can spread or be uncomfortable for the child.

There is actually a specialized dental aid, called a tongue cleaner , which works very well also.  It’s not very appealing, and works by simply scraping the layer of bacterial tongue film off.  They are safe for adults and children to use, but I prefer brushing just because I already have enough “icky” things at my house from parenting two boys!  Be sure when brushing that you are reaching far enough back on the tongue.  Sometimes this will cause the child (or adult) to gag in response.  Just do your best to reach where you can!

Another common cause of this amazing “phenomenon” is poor brushing technique and/or not spending enough time brushing.  Those of you who have kids in the older age range are probably all too familiar with these types of amazing “phenomena” in other areas of your family life!  Your child should spend at least two minutes brushing their teeth at least twice a day with an American Dental Association approved, fluoridated toothpaste (please refer to the next section of the book for age-appropriate times for introduction of toothpaste).  Poor brushing technique and lack of adequate time leaves that layer of “fuzzy” plaque on your teeth.  That plaque is actually a thick film layer of bacteria and food debris and can be quite smelly.

Over time, if this layer is not removed, it starts to become hard and cannot be removed without scraping with a special instrument at the dentist.   This “hard stuff” is called tartar (your dentist calls it calculus).  When it gets stuck on the teeth and not removed, it is the culprit that causes gum disease.  This tartar layer then starts to build upon itself, sticking to one layer after another, ultimately spreading beneath the gums.  The body then views this concrete-like stuff as a foreign substance and tries its best to be rid of it.  The entire process is really astounding, really.  Pretty nifty when you think about how well our bodies are at fighting invaders!  Unfortunately, this nifty little process has some big, bad side-effects.

In the body’s great attempt to get rid of this villain called tartar, it emits some harmful chemicals to other parts of the mouth.  These tiny little chemicals are actually destructive to the bone which hold the teeth in place.  They slowly erode that bone away and little by little the teeth become loose.  So loose in fact, that the teeth can eventually fall out on their own or have to be extracted by your dentist.

This viscous, destructive cycle is what we call “gum disease” but your dentist will refer to it as “periodontal disease.”  Don’t get confused, they mean the same thing!  Gum disease can range from mild to severe and treatment for it depends on the severity of the disease.  Another term you may here is “gingivitis.”  Gingivitis is the early stage of gum disease. At this stage, no bone has actually been lost, but the process is on its way if not treated with a professional cleaning and better oral hygiene

As a dentist, the gum disease process is one of the most devastating and saddest of all dental problems for me to see.  The reason for this is because in most cases, it is completely preventable and curable if treated early.  The cure is so simple but the effects of no treatment are life altering.  I have seen more tears than I care to share with you from premature loss of teeth in young and otherwise healthy people.  Loss of teeth can be a very emotionally upsetting experience for many people, especially when it occurs in the front of the mouth.

Now going back to our non-compliant little adults and tykes. I know what you’re thinking.  I have tried to make my child brush their teeth.  I tell them all the time and they just don’t do it.  How am I supposed to get a teenager to brush?  I don’t have time to look over their shoulder.  The great news is, no shoulder looking is usually required, because you can smell it from a mile away!  The only suggestion I have to offer here is using whichever form of discipline you use normally (assuming it doesn’t involve lashings or something similar)!  For me, personally, I find taking favorite toys, gadgets or privileges away to be handy and often successful!

Another way is to be able to show the child the amount of “grime” on their teeth.  This is also one of my personal favorites, as it tends to “gross-out” most older kids and encourage them to brush better.  For younger kids, it is actually fun and a form of entertainment!  There are several ways you can show them.  One of the best is to ask your dentist for plaque tablets (called disclosing tablets).  They are usually purple or pink and about the size of an aspirin tablet.  The child will chew it up, swish it around in their mouth and then spit it out. Then, voila-you have a brightly stained layer of bacterial fuzz which they have to brush off!  Not only will this show them how much they are missing while brushing, but it will also get them used to how long and how much pressure they need to use to adequately brush their teeth.

There are also over-the-counter plaque dyes that can be used such as “Agent Cool Blue” by Listerine and a few others.  However, my experience has been that the professional dyes (disclosing tablets) work much better but are a little trickier to find.  Your dentist should be able to help you find the tablets if you are not satisfied with the results of the over-the-counter stains.

Speaking of stain-those little tablets and swishes are also fabulous as staining lots of other items, so you may want to supervise the process!  As mentioned earlier, the child should be old enough to rinse and spit the mouthwash out without swallowing to avoid any potential toxicity.

There are also other more concerning reasons for the malodor.  Though uncommon, other reasons include tooth decay, gum disease, gastro-esophageal reflux and other disease processes.  So be sure to take your child to the dentist for a thorough exam if tongue brushing or better brushing  doesn’t remove the odor.

If you have never seen an x-ray of a newborns jawbone you may be surprised to see 20 developing teeth. So, even though you can’t see them, they are there. This is one reason that illness or injury as a toddler can have adverse effects on teeth later on. Your toddler’s first teeth are known as”primary” teeth and play an important roll in development. It is important for parents not to treat their child’s primary teeth as “temporary” or “replaceable” . Many preventable problems can be avoided by proper care of your toddler’s primary teeth.

At about six month of age, your toddlers teeth may be starting to erupt. The front four teeth are usually the first to arrive. Remember that ever baby develops at a different rate so if your toddler does not have his or her first tooth at 6 months+one day ,don’t sweat it! It is not uncommon for the first teeth to take 12 to 14 months to come in. Both of our boys seemed to take forever to get/lose teeth.

When your toddler’s teeth begin coming in(erupting), your child may experience sore or tender gums. This is normal. You can help soothe the discomfort by gently massaging the gums with a clean finger or moist gauze pad. Granted this will only provide temporary relief but sometimes that’s enough to help a fussy baby. If you prefer the “hands off” method, you can give your toddler a clean teething ring to chew on. Remember never to put any sugar or syrup on the teething ring. I know it seems obvious but as you may have guessed, there is a reason I mention it!

If your toddler is excessively uncomfortable and cranky, you can call your dentist or pediatrician to ask about over the counter pain remedies. Keep in mind also that contrary to popular belief, if your infant/toddler is running a fever while teething, this is not normal. Any unusually high or persistent fever is an indicator to contact your pediatrician.