If your dentist determines that your child’s teeth are in fact darker than normal and your child is concerned with their appearance, then there are a few things to consider. I get this question often, and my answer is always the same: wait until your child is at least 18. There isn’t necessarily a specific age that is appropriate for your child to use whiteners. I base my opinion on what little research exists on the use of whitening agents in adolescents. Always consult your family dentist prior to trying any over-the-counter whiteners on your child.

As you may or may not know, there are several ways to whiten teeth. All have one similar feature: the use of a whitening agent such as hydrogen peroxide, carbamide peroxide or other agents. Some techniques use a special light during the application of the whitener to enhance whiteness (i.e., Zoom Whitening Sytem). Others use customized trays in which the whitener is placed and worn on the teeth for a certain period of time and for a certain length of time. These are both considered to be professional grade whiteners, and my personal preference is for the custom tray method, as whitening can be controlled by the patient and there is typically less sensitivity. Over-the-counter methods include “Crest Whitestrips” and its “Rembrandt” competitor.

Whitening agents can cause sensitivity to both the teeth and gums, and can sometimes be much more exaggerated in young teeth. This can be a painful experience, and quite troubling for teens and adolescents. The other main concern, particularly with the accompaniment of the light accelerator, is damage to the nerve tissue within the tooth (also called dental pulp). Few studies have been done on teeth whitening in adolescents, but some hypotheses of whitening in youth are, that it could cause damage (either irreversible or reversible) to a child’s teeth. This thought pertains to any method used for whitening.

Damage to the pulp can be reversible or irreversible and so symptoms may be as minimal as sensitivity, but can also result in death of the dental pulp. If death of the pulp occurs, a root canal is then needed to permanently eliminate the pain. There are not a lot of studies done in this area, because as you can image it raises some ethical dilemmas in order to gather the data. In adults, however, whitening is considered to be very safe and non-damaging, assuming you follow the direction for the brand of whitener. Though adults may experience some sensitivity, generally it is transient and not a problem.

So, my personal philosophy is, I don’t whiten teeth unless the child is at least eighteen, so that the tooth tissue has time to mature. If the child’s teeth appear to inadequately matured, regardless of age, I may still suggest waiting a little while. This maturity will hopefully allow for minimal sensitivity and hopefully no tooth damage. While in general whitening teeth is perfectly safe, we still must use caution when considering them as options.

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.

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.

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.