Of course, we already discussed earlier in the When should I first take my child to the dentist? post that your child should start seeing the dentist early and we also learned that they should go for check-ups and cleaning every six months. At the check up appointment, the dentist may want take a few x-rays.  There are many different types of x-rays that are considered acceptable for a child, and it really depends on what the dental team is looking to evaluate.

Generally speaking, usually around three or four years old, check-up x-rays (also called bite wing x-rays) may be taken if the child does not have spaces or has limited spaces between the baby teeth or if decay is suspected in an area between the teeth. Children at this age have very small mouths, and so typically all is needed are two of these films (understand that this may vary depending on the child).  These films are done every year to eighteen months, again depending on the child.  There really isn’t a minimum age requirement for these check-up x-rays, it is really dependent on the spaces between their teeth and the visibility between them.  These x-rays are done to look for cavities in between the teeth, thus the reason they may not be necessary to take if the child has adequate spaces between their teeth.  If spaces are present, the dentist can usually see the tooth directly without the use of x-rays.

At around age 5 or older, your dentist may choose to take another x-ray called a panorex or “panoramic film.”  This film does not look for cavities but rather is a tool for evaluating possible missing teeth, disorders of the jaw including cysts, tumors (cancerous and non-cancerous) and a myriad of other things.  It may also be used to aid in orthodontic evaluation in the future.  This is a film that is typically done every three to five years or even less depending on the use for the x-ray.

There are other x-rays sometimes done for other reasons.  One more commonly done x-ray is called a “P.A.”, which stands for a periapical x-ray.  It is just a fancy dental word for an x-ray that shows the entire tooth, including the root and the surrounding bone and is usually done on children to evaluate a possible abscess or to determine the length of time until a permanent tooth will erupt.  This is an acceptable x-ray for children at any age if the dentist has a concern about a specific tooth.

Another film that a parent may encounter at the dentist is called an occlusal film.  This is a film that may be taken of either the upper or lower teeth and is meant to see a better three dimensional view of erupting teeth or pinpoint pathology within the jaws.  This kind of x-ray is not done that often, but is very important when trying to determine very specific details that would otherwise not show up.  It is usually only done if the dentist has a very specific reason for taking it.

One question I am frequently asked regarding x-rays and children are about the relative danger to the child.  In general, x-rays in moderation are considered to be safe when precautions are taken to minimize radiation exposure.  This is the same for adults.  In fact, we are often taught in school that we receive more radiation exposure from the sun on a single day then we do in a set of yearly x-rays.

For children, it is especially important that the areas sensitive to radiation are covered during x-rays.  These areas include the thyroid/neck area as well as the reproductive areas of the child.  This shielding is done with a lead apron.  Dental offices are also required to undergo annual testing and evaluation of the radiation equipment (this varies by state) to be sure they are in compliance with state radiation regulations.  In addition, most states require that the staff taking x-rays have completed a regulated x-ray dental safety and technique course in order to take x-rays.  These certificates will usually be posted for patients to see.

The answer I am going to give you is going to sound ridiculous at first, but if you listen to my reasons, you will see exactly why we recommend the following:  In general, a child should first see the dentist when their first tooth comes in.  There are two reasons for this.  The biggest one, at least the one they teach us in dental school, is because teeth exhibit many possible signs of underlying bodily diseases that may otherwise not be discovered until a much later time.  There are many genetic disorders and syndromes that show their signs first in the teeth before in any other part of the body.  A few examples include ectodermal dysplasia, amelogenesis and dentinogenesis imperfecta and many more. While most of these disorders are indeed somewhat rare, I think common sense tells us that the sooner we can catch them, the better opportunity we have to treat them.

In addition to this, parents must remember a long used phrase about children: “Kids are NOT little adults.”  Now, I am sure this makes complete sense to you when you think about the daily things, like why kids think it is fine to eat mac n’ cheese for every meal or why they still can’t put their shoes on the right feet at 10 years old.  Or how they can have 103 degree fever and still be functional when us adults would be bedridden and begging to be put out of our misery.   So, this phrase is applicable in many areas, but is particularly true in the world of dentistry.

One thing parents need to know about their kid’s teeth is that children’s teeth are “softer” than adult teeth and therefore decay at a much faster and easier rate.  Not only are they more susceptible to decay, their nerve tissue within the tooth is much closer to the outside of the tooth than an adult.  This makes it much more likely that they will need a “child root canal” or extractions, even with the presence of only small amounts of decay.  So, with this in mind, we can see how an early trip to the dentist can minimize problems which may have otherwise become huge problems by waiting.

Another important thing to know is that those baby teeth which seem so unimportant are actually a blessing in disguise.  As you will read in subsequent chapters, those little teeth will help pave the way for the future position of the permanent teeth.  Extracting them prematurely can cause many cosmetic and functional problems which can be very costly later on.

While I am a dentist, my most challenging job is being a mom.  That is why I actually feel that this next reason for going to the dentist at an earlier age is one of the most important. I have rarely seen a child in this age range that is eager and excited to hop up in a large, squeaky chair, in an unfamiliar place and open their mouths for a total stranger wearing latex gloves and a scary mask.

To top it off we expect them to open willingly and let us come at them with large, sharp instruments. Yikes!  If they scream just sitting on Santa’s lap, what makes us think they will be excited about going to the dentist?  If we take our children young enough and make it a fun place without all the scary stuff first, then their visits will be an experience to look forward to rather than fear.  So, the mom side of my persona always wants me to create fun and wonderful experiences for my kids and the kids I treat.  The earlier they start seeing the dentist, the less fearful they will be.

I usually suggest that you bring them in with you when you have your own cleanings done every six months (provided you, yourself are not a big chicken).  This will reinforce that you are not scared and get them familiarized with the office so that they are comfortable with the surroundings.  Eventually, the child will recognize your dental office and look forward to coming with you because they always get a toothbrush, a sticker and a sugar-free lollipop!  The biggest miracle of all is, that after a few times, you’re little one will actually beg the dentist to look at their teeth and will ask them to be cleaned.  Easy as taking candy from a baby (which, by the way, your baby shouldn’t have candy in the first place-but we’ll talk about that more later)!

If you, as a parent, are a dental-phobe, then have your spouse or someone else take your child so that they ALWAYS begin their dental journey with nothing but a positive experience.  Keep in mind that if someone other than the child’s legal guardian takes the child, you will need to give the caretaker some form of written and/or verbal consent for treatment.  The laws vary by state, so be sure to inform yourself and also keep good communication with the dental office staff about treatment and finances involved in your child’s care.

If your child is still uncooperative despite all efforts, or your current dentist is not great with kids, then I would highly recommend seeing a pediatric dentist.  This kind of dentist sees only children and has the entire office set up for kids, from music, TV, giant kid-friendly murals, puppets and most importantly…sedation.

My general feeling about sedation is that if it is necessary to help your child have a great dental experience, then strongly consider it.  If you have to consider sedation as an option, please be sure to discuss with your dentist all of the risks involved with this type of chosen sedation.  While sedation is a great opportunity to complete your child’s dental care with ease, there are risks you should be aware of.  Though rare, there is the possibility of accidental death as a result of sedation and so the procedure should be considered only if truly necessary.  Due to the wide variety of sedation options and the fact that selection of the type of sedation varies by child,  I will not go into specific details.  Just inform yourself well and use that information to aid in making your decision.

By and large, the number one complaint I hear from my adult patients who are terrified to go to the dentist is that they had a traumatic childhood dental experience.  If we start out positively as a child, then we will have no reason to fear the dentist as an adult.  Going to the dentist regularly will become a desired, regular occurrence, like birthdays or  holidays.  Okay, okay, maybe I am exaggerating a little, but they still can be fun experiences for kids!

These bi-annual check-ups and cleanings allow us to catch problems while they are small, thereby keeping most dental procedures extremely conservative for both kids and adults.  I know it may seem hard to believe, but going to the dentist really can be an enjoyable (not just a tolerable) experience.

Much of what I will tell you in regards to nutrition will be similar to what you may have already heard from your obstetrician. Of course, nutrition is crucial to the overall health of both mother and child. A balanced and healthy diet can help mom feel well, avoid pregnancy complications such as gestational diabetes and aid in proper development of the baby.

But proper nutrition also plays a key role in the developing baby’s tooth enamel. Proper amounts of vitamins A, C and D, phosphorus, calcium and protein will help yield stronger, more decay resistant baby teeth in your child. Many of these vitamins and proteins are absorbed by consuming foods such as fruits, leafy vegetables, non-fish meats and low-fat dairy products. In addition, always add a prenatal vitamin to your diet unless your doctor says otherwise.

First, dentists are definitely not all the same.  True, most of us start off with the same initial dental degree (Doctor of Dental Surgery) however, what happens after this may or may not make a huge difference.  Like medicine, dentistry has a multitude of specialties. I know, you may be thinking, “How could there possibly be that much to know about teeth?”  The truth is, that there really is that much to know about teeth. Not to mention the teeth are connected to the mouth, which are connected to the head, which is connected to the body, etc., etc.

The problem with teeth is just that. They are connected to everything else in one way or another.  The amazing thing is that so many disorders actually show up in the mouth before they appear anywhere else in the body.  So, the mouth can be a fantastic place for a first diagnosis that physicians often miss.  In addition, we prescribe and use many of the same medications and anesthetics that physicians do.  It really isn’t as simple as “drill and fill.”

Though we all start out with the same initial dental degree, some doctors choose to specialize in a particular area of dentistry.  There are a few reasons for dental specialties. First, there are many different dental needs and levels of complexity.  One type of dentist cannot adequately fulfill all the treatment needs of all individuals.  In addition to this, the type of patient (i.e. adult, child, elderly) and the medical needs of the patient all impact treatment and thus the type of individual care needed.

Dental treatment can range from very simple to highly complex, involving multiple specialties in order accomplish a final outcome.  It really isn’t possible to know everything about everything (But don’t tell my husband I said that)!  Just as I wouldn’t want my family practice doctor to perform brain surgery on me, I would not want a general practice dentist to perform my jaw surgery.

There are currently nine dental specialties recognized by the American dental association. These specialties are Oral Pathology, Oral Radiology, Endodontics, Periodontics, Pedodontics, Prosthodontics, Oral Surgery, Orthodontics and Public health.   Each of these specialists will have the same initial degree as your general/family dentist (Doctor of Dental Surgery) but have continued their education for an additional 2-6 years in specialty training for a specific type of dental treatment.  They are the highest trained in their area of expertise and are limited to performing only those procedures for that specialty.  For example, a pediatric dentist does sees only children and will not provide care for those over 18 years of age.  An Endodontist does only root canals and root canal surgeries, never fillings, crowns, etc.

The chart below lists the above named specialist and the type of treatment they provide.

Oral Pathologist:  Evaluation, diagnosis and treatment of oral or head and neck diseases out of the comfort or expertise level of any other type of dentist.

Oral Radiologist: Evaluation and diagnosis of x-ray findings of the head, neck and jaw out of the comfort or expertise level of any other type of dentist.

Endodontist:  Evaluation, diagnosis and treatment of root canal related problems or procedures out of the comfort or expertise level of any other type of dentist.

Periodontist:  Evaluation, diagnosis and treatment of gum disease or gum procedures out of the comfort or expertise level of any other type of dentist.  Periodontists also place dental implants and perform regular cleanings to patients with a history of gum disease.

Pedodontist:  Evaluation, diagnosis and dental treatment of children 18 years or younger.  They are typically certified to perform most sedations types and have privileges to practice in a hospital setting if needed to complete child’s care.

Prosthodontist:  Evaluation, diagnosis and treatment of any patient that requires more complex dental care beyond the comfort or expertise level of any other type of dentist.  These dentists will be more experienced with treating patients requiring very complex crown/bridge work, dentures or implants.  There is also a subspecialty of prosthodontists trained in facial reconstruction with prosthetic noses, eyes, oral structures, etc.

Oral Surgeon:  Evaluation, diagnosis and treatment requiring surgical methods or advanced laser procedures.  Some of these surgical procedures include wisdom teeth or other complicated extractions, placement of dental implants, oral/facial biopsy service, facial cosmetic surgery, jaw reconstruction and much more.  They are certified to use the wide range of sedation and anesthesia techniques and also have privileges for hospital-requiring treatment.  Many oral surgeons are also physicians.  This will depend on the oral surgery training program they decide to go through.

Orthodontist:  Evaluation, diagnosis and treatment of dental and skeletal problems requiring orthodontic care (braces and orthodontic appliances) out of the comfort level or expertise of any other type of dentist.

Public Health Dentist:  Evaluation, diagnosis and dental treatment in dental under served areas.  Research and statistic oriented and spends a significant amount of time studying, education and publishing information related to dental health of the public, especially in dental under served areas.

In many cases your family dentist can treat a multitude of dental problems which could also be treated by specialists.  However, specialist treat dental issues in their area of expertise which are much more complex and difficult that a general dentist would.   So, you family/general dentist may choose to refer a patient to a specialist on occasion.  This usually occurs when the level of training or experience your family dentist has is out of their scope of care, or they are not comfortable performing the needed treatment.

So the fact that your family dentist recognizes that they cannot be a master of all things is actually a very good thing, albeit an inconvenience for you.  This suggests that your dentist understands their limitations and wants what is best for the patient rather than what they can gain financially.

What you will find if you see enough general/family dentists is this: There is a significantly wide range of comfort and skill levels between general/family dentists.  While some dentists are perfectly happy and skilled at treating children, another dentist may prefer not to treat children because they are not comfortable or patient enough to work on children.  The same principle applies to many other areas of dentistry.

At the other end of the spectrum, there are dentists who elect not to refer out certain procedures to a specialist that they really should. There are plenty of procedures that practitioners are legally allowed to do but really should.  This could be from their lack of experience with the procedure or because they really just don’t have the skill or ability to do it.

One thing you must understand is that we, as practitioners cannot be perfect at everything.  We, of course want to be great at it all, but it is my strong feeling that we must recognize when a procedure done by a specialist rather than ourselves is in the best interest of the patient.  Sure, we could probably do it, but if we don’t do it really well, then I believe we are doing a disservice.

So, my general rule of thumb is that if you feel in the pit of your gut that something just isn’t right with the dentist you are seeing, then pay a little extra to have a second and possibly third opinion.  In our world today, we like to believe that everyone has great morals and ethics and everyone who graduates with a professional degree “knows their stuff”.  This just isn’t always true.  Always go with your gut instinct whether the dental visit is for yourself or for your child.  Remember the old joke, “What do they call the guy who graduates last in medical school?”  That’s right, they call him “Doctor.”  The same joke applies to dentists!

The other item on the agenda to discuss is, when choosing a dentist, you should always take into consideration the facility itself. Again, this is a go-with-your-gut kind of thing.  Does the facility appear clean and tidy?  When you are in the treatment rooms does it appear that the sinks and counter tops where dental tools are placed are wiped down? Understand though, that we use a lot of products which stain counter tops and chairs, regardless of how much you attempt to scrub it off.  It’s a lot like the impossible grass stains on the baseball uniform.  But an overall clean and organized facility can be an important reflection on the quality of care you or your child may receive.

Does the technology appear to be current or does it feel like you are in an antique store rather than at the dentist?  Technology has evolved considerably in the last ten years and you should start to see that same evolution in one form or another in the office.  Some of these changes may include patient education literature, computers in the office, possibly digital x-rays and just an overall appearance if being current with the times.

Are the staff, including the dentist wearing gloves and a mask while they work on you/your child?  Are they taking check-up x-rays every 12 to 18 months?  Do they ask about your child’s health history at every check up to see if it has changed?  Do you feel that the staff and dentist speak with confidence and sound generally knowledgeable? Also, don’t confuse arrogance with knowledge, which can sometimes cause things to be missed during a dental exam! Does your child’s dentist and staff try to educate you on dental procedures needed and ways to prevent future problems?  Does your dentist actually listen to you when you talk?

For adults, does the dentist actually take more than a minute to look around your mouth at everything?  Or do they just look quickly with a mirror and say that “everything looks good?”  Do they actually look at your x-rays?  Does the dentist or hygienist check your gums with a special instrument to check for gum disease (this likely won’t be done on your child unless the doctor suspects it, as gum disease is uncommon in children). Does the dentist or hygienist check deliberately for “lumps and bumps” inside and outside of you or your child’s mouth?  This is called a head and neck exam and should be done every six months to be sure that there is no evidence of cancers, tumors or other pathology.  Do you never have anything wrong at every check-up for years?  It is common to have small cavities or cracks come up throughout the years.  It is actually more abnormal to have patient that NEVER has anything wrong, even if it is minor.

It does happen, but if you see or feel changes in/on your teeth and your dentist always says “it’s fine,” and/or never takes an x-ray of the area, you may want to get a second opinion.  Many times dentists choose to “watch” things rather than fill them in an effort to be conservative.  Sometimes these things we “watch” are truly just stains but sometimes they are not and cavities can grow quite large without getting a “stick,” as your dentist might say.  That “stick” is a sticky sensation when we touch a special dental instrument to a suspicious tooth.  If the instrument “sticks” or “pulls back” when we push on it, generally that means there is a cavity.  However, cavities can grow beneath the surface of the tooth and the tip of that special instrument may be too large to fit into the hole. Therefore, there may not be a “stick” even though a cavity is present.

These are all questions that you should think about at your visits.  If these things are not being done, then I strongly suggest that you get a second opinion to be sure that things are not being missed.  Always go with your instinct.  If your “gut” tells you that something is not right, don’t second guess yourself.  It is always better to be on the safe side.  It can’t hurt to have a second opinion and you may feel comforted after doing so.