My decision to create this site was made because of the many questions I get as a dentist from parents regarding their children’s oral health. It seems that many of the “What to Expect ” books and childcare guides omit something very critical in raising and caring for children. A subject that is so simple but so easily dismissed as common knowledge or topics that your pediatrician will discuss with you. Unfortunately, most pediatricians know VERY LITTLE about the dental health of your child. So, this leaves many parents wondering if they are providing adequate dental care for their children. Too often this lack of knowledge causes irreversible damage to their kid’s teeth and a serious dent in their wallets.

I hope you find the information on this site to be a  mildly humorous, very informative, myth-busting, easy to understand guide that should help you feel confident that you are on the right track with your child’s oral health. My other hope is that this knowledge will allow you to save money when it can be saved, and to spend it when it really needs to be spent.

These questions were chosen because they are by far the most common I receive at the dental office or more often, when I am at social functions for my own kids! The answers are then provided in a way which I think just about everyone can understand. I hope after reading some of these posts, you find yourself empowered and fully informed.
I hear all of these questions far too often, which leads me to believe that there is a serious lack of knowledge on the subject. Since dental decay in children is the #1 childhood disease, it is very important that parents are well educated on the subject. I feel strongly that we can better help the future of our children if we can share the knowledge to prevent these dental problems. These problems are far too often physically, mentally and financially challenging for parents and children, both short and long term. So, my hope is that after you find something useful or helpful, you feel confident in sharing the vital information with others so that they too can avoid some of the costly or worrisome situations.
You may also have friends in your social circle with younger children who may have questions that you will now feel confident answering for them. Even though you may only have a teenager now, life can be full of many unplanned miracles-so it is always better to be prepared now! Whatever the reason, share the knowledge with your friends and family.

If I had a quarter for each time I was asked this question, I would be retired on a beach, relaxing with an umbrella drink in my hand! This question, as well as the one after it, has many different answers, depending on who you talk to. The reason being is this: Removal of wisdom teeth is predominantly a practice philosophy rather than an exact science. What I mean is, there is much leeway, discussion and debate among all types of dentists as to what is the best treatment of wisdom teeth is. So, what I will give you is my personal philosophy, but the decision is ultimately yours!

Wisdom teeth are the last teeth to erupt and are the teeth furthest toward the back of the mouth. They are also referred to as “third molars,” and will frequently never appear in mouth. This can be due to lack of space in the mouth or simply because many people are born without them. Often times, there is no room for the wisdom teeth to erupt, leaving them trapped in the jaw or only partially erupted. So let’s discuss a few of the problems which arise from extracting them vs. leaving them and you will quickly see why there is so much debate.

If the wisdom teeth do have space to come in completely, then a few scenarios can occur. If your child is able to reach all the way back there and keep them immaculate, then typically there are not any problems with keeping them. However, it has been my experience that few adults are able to keep them clean enough to avoid cavities or gum disease around the teeth. It is extremely rare that I actually get to witness the miracle of cavity-free wisdom teeth. Generally, it takes awhile to get a cavity back there (it usually shows up in your mid-twenties to mid-thirties.)

Once a cavity is present, the tooth either needs to be filled or extracted. Attempts to fill wisdom teeth are mediocre at best, unless you have the ability to open very wide. Because the teeth are so close the jaw-joint, it is very difficult for the dentist to see if all the decay has been removed, or keep the tooth dry enough to retain the filling.

In most cases, the filling eventually fails and the tooth has to be extracted anyway. The same holds true for gum disease. Because they are hard to clean, they very often are afflicted with moderate to severe gum disease. If left, the gum disease can cause bone loss around the tooth, bad breath and possibly increase the risk for spreading the disease to the rest of the mouth.

As adults, we heal much slower, experience more pain and have the added trouble of having to take time off of work. I personally tend to be more pro-active with recommending extraction of wisdom teeth, especially those that will likely fully erupt into the mouth. This is because I know the child will be thankful I did once they are an adult!

The other advantage is, that when you remove the wisdom teeth before they are completely developed, they are actually much easier to remove. This results in less pain after surgery, faster healing time and less of a risk of complications from the procedure. So, the possibility of reducing these risks by extracting them as an adolescent is very appealing to me as a mom and a dentist!

Well, let’s suppose that the wisdom tooth is not in at all, partially in (but stuck that way), or has no space whatsoever to come in. An x-ray (a panorex or panoramic film) will have to be evaluated by the dentist or oral surgeon before a decision can be made. Most times the teeth can still be removed with relative ease and without complication. However, there are situations which may predispose your child to temporary or permanent complications.

Close proximity of the lower wisdom teeth to the main nerve supplying all the teeth can be a concern. Injury to this or any other nerves in the areas can cause partial or complete, permanent or temporary numbness to the lip, chin, teeth, gums, tongue or skin in the area. In addition, the top teeth may be so high up in the jaw that risk of damage to the sinuses and other structures can occur. Your oral surgeon will be aware of these complications and any others as they apply to your child.

So, if the wisdom teeth seem risky to extract and the likelihood of the teeth ever erupting is low, then I typically recommend leaving them. The benefits of extraction must be carefully measured against the risks involved and be sure to discuss them in detail with your surgeon.

I also want to bring up the importance of the oral surgeon here. As we discussed earlier, specialists exist in dentistry because they are necessary! While there are general dentists who can take out wisdom teeth with great proficiency, I still strongly encourage having an oral surgeon perform the procedure.

An oral surgeon does this procedure every day, many times a day and they are simply better, faster at it and are more familiar with the complications which can occur from their removal. They are also more familiar with the internal jaw anatomy which is rarely seen by a general dentist. This is not to say that a general dentist is not capable, as there are plenty out there that would do just as good as any oral surgeon. However, my experience has been that this is the exception and not the rule.

Believe it or not, this situation is relatively common. This too tends to run in families, but not always. This brings back the important topic of x-rays. This situation is usually first noted when they child has the panoramic film taken around age 5-7. Typically, though not always, teeth will be missing in pairs. They are also usually missing the same tooth but on different side of the jaw. For example, the child might be missing both lower first premolars/bicuspids on the right and left bottom, but not on the top.

When this does occur, most dentists will give you the same advice: Do everything you can to take care of and keep the baby tooth so it can maintain the space and function of the missing permanent tooth. This is because it holds the space open for future treatment (if needed), which may otherwise be complicated by loss of the space.

If the tooth cannot be maintained, the dentist may suggest the use of a space maintaining appliance (discussed in the general questions section). There are situations where the baby tooth may actually be better of being extracted. For example, if the child already has abundant crowding, then this may actually alleviate the need for braces.

So, always talk to your dentist or orthodontist about what the best option for your child may be. If the baby tooth is unable to be retained permanently due to looseness or an extensive cavity, there are options to replace the tooth in adulthood if necessary. A few examples of what those options may be are: Dental implants, fixed bridges, denture or retainer with a tooth on it. Again, discuss these options with your dentist and see which one will best suit your child.

A very frequent question indeed, and one which you will likely be relieved by the answer! This is a very common situation and is usually at its worst between the ages of ten and twelve, depending on the child. It is so common in fact, that it has been given a name by orthodontists. It is called the “ugly duckling” phase of dental development.

Most times, the gap will resolve on its own once the permanent canine teeth come completely in ( around age eleven). This gap is caused by the canine teeth pushing on the roots of the front teeth as they make their way down into the mouth. This pressure pushes the teeth in the front apart temporarily and will start to close as the canines come further into the mouth. It can be a little embarrassing for teens until it resolves. So, reassure them that many of their other friends are likely to go through it also, and that it usually goes away on its own.

Occasionally, however, the gap remains slightly. This will depend on the skeletal and dental relationship of your child. If the canines have come in, and have been in for awhile but the gap still remains, talk to your dentist or orthodontist. There are many options for treating this if your child is unhappy with the final appearance of their smile. Some of those options may include anything from a small, tooth-colored filling placed to widen the appearance/close the gap, to brace or other appliances. Each child and situation is unique.

This problem doesn’t occur too frequently, but when it does it leaves parents scratching their heads in curiosity. There are a few reasons this can occur and all will require a trip to the dentist for an x-ray and evaluation.

As mentioned in the second section, developing permanent teeth can be affected by a variety of things including high fevers, certain antibiotics and trauma to the baby tooth (transmitting trauma to the underlying permanent tooth). Permanent teeth can also be affected when they are traumatized directly once in the mouth.

How these “damaged” teeth will react really depends on the type and severity of the trauma. Some teeth will still “survive” but may appear malformed or have some kind of distinguishing mark on them. Others may not have been able to tolerate the trauma and eventually “die.” This “death” simply means that the living tissue inside the tooth (called the pulp) are damaged to the extent that they cause death to that tissue. That living tissue, or “pulp” is the nerve and blood vessels which supply the tooth sensation and sometimes, outward color.

When a tooth “dies” or is in the process of “dying,” the entire tooth undergoes multiple changes which can have many effects, many of which differ slightly depending on the individual.

Occasionally, a traumatized tooth may undergo a reaction with the fancy name of “calcific metamorphosis.” Wow-what a word! It simply means that the tooth felt the trauma and reacts to it by laying down extra layers of minerals within the tooth. This layering of extra minerals (which is really just extra tooth structure), results in a “squeezing” down of the pulp or living tissue located inside the tooth. This frequently, but not always, causes death to that living nerve tissue inside the tooth (the pulp).

This death doesn’t always occur, but does eventually in a high percentage of teeth. This strange process of laying down extra layers of tooth actually causes the tooth to turn more yellow that the other teeth. Treating these teeth can be complicated because though they usually do die, they don’t always do so, regardless of how yellow their color becomes.

Typically, if the tooth doesn’t reveal signs of death when the dentist evaluates it, they will choose to do frequent x-rays and re-evaluate at certain time intervals. They will also have the parent keep a watchful eye for any signs of tooth death such as, pain, change in tooth color (grey or further yellowing), swelling, a “bump” on the gum, or a foul odor coming from the child’s mouth.

If the tooth is confirmed to be dead after evaluation by the dentist, then a root canal is usually done to rid the infection that comes with the death. A root canal usually does not hurt, despite popular myth, and is simply the removal of the dead tissue from within the tooth. The tooth is usually numb for the procedure but doesn’t always have to be, depending on the situation. Once the dead tissue is removed, the inside of the tooth is cleaned and sterilized with tooth-friendly substances. The area is then filled with a special rubbery material to seal it off from other possible bacterial invaders.

Unfortunately, this usually will not fix the color change that has occurred, and occasionally it can become more exaggerated. There are several things which can correct the color change, including procedures such as, internal whitening of the single tooth, a veneer or crown. They may also be able to place a simple, tooth-colored filling that is layered on top of the tooth to mask the color. Each of these are too detailed to describe here and require that you discuss the suitable options for your child’s particular circumstance.

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.

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!

Another form of sedation which many parents opt for is “laughing gas”. The medical term for “laughing gas” is nitrous oxide sedation. It is a combination of nitrous oxide and oxygen gases, administered to adults and children through a little mask which fits on the nose. The patient breathes in through the nose and the gas flows through the body allowing a general sensation of overall relaxation. The gas does not put you to “sleep” in the medical definition sense (either general or twilight anesthesia/sleep), but rather can truly allow you or your child to fall asleep during a procedure.

During other sedation procedures, the definition of “sleep” has to do with a temporary nervous system alteration (almost like being paralyzed) and the patient may stop breathing part or all of the time. During non-breathing periods, the patient’s breathing is provided by artificial means and controlled precisely throughout the “sleeping” period of the procedure.

With laughing gas, breathing is never stopped (at least not on purpose) and any “sleep” obtained is by the same means in which we do at night. Most times with laughing gas, the patient stays awake, but is so relaxed, they don’t care what is going on. They can usually carry on a conversation in some form and are very aware of what is going on. However, if their bodies are the type to be sleepy from laughing gas, they may not converse or be very aware at all.

Once the procedure is over, the dentist should allow the patient to breathe pure oxygen for five minutes to flush the remaining laughing gas out of the body. One of the best advantages of laughing gas is that once the gas is removed, the patient is usually fully returned to their normal mental and physical state with no side effects. The patient usually remembers everything about the entire experience unless they fell asleep.

Every person reacts differently to the gas. Some people laugh or become “silly”, but most people just feel relaxed or feel as if they have had a few glasses of wine. The gas only works if the patient breathes it in and the patient can more or less control their level of sedation by how they breathe. The gas dosage is also controlled by the dentist, but both the patient and doctor will both have some control in obtaining the desired effect. Unfortunately, there are some people, children included, that are not affected by the gas at all. This doesn’t occur often but can be frustrating for both the patient and the dentist.

In general, laughing gas is very safe when given appropriately. There are very few medical conditions that make the gas impossible for use. These are rare and your dentist should consult your child’s physician if there is any question. Laughing gas can pose some dangers, just as with any medication given. One of those dangers is overdose on the gas. The maximum percentage of laughing gas that can be given before “overdose” can occur is at ratios greater than seventy percent nitrous oxide.

Almost all nitrous oxide units today are now made so that it is impossible to give more than 70% nitrous oxide. They contain a special internal regulator that will not allow it to give gas at levels higher than 70 percent. Older offices may still have some of the dated laughing gas equipment that allows you to go beyond the seventy percent dosage. If you or your child are seeing a dentist in which the office appears “out of date” with respect to technology or the appearance, be sure to ask if their laughing gas unit has the protective device on it.

Laughing gas is a great first option to consider for your child should they need any form of sedation. If your child is a “screamer” or very apprehensive, you may find that they will refuse to even put the mask over their nose. Exceptionally fearful children may have the same problem, but you can always attempt it and move forward with another type of sedation if unsuccessful. Remember, the goal here it to give children a positive dental experience so they don’t acquire dental phobias as adults. So it will often require a team effort and a lot of patience!