First, if the tooth is only fractured part of the way off, call your dentist immediately. The child will need an x-ray, evaluation and treatment right away to help prevent further complications.

If the tooth has come all the way out (called and avulsed tooth), there are a few things which need to be done and all must be done quickly for the tooth to have any chance of surviving. First, find the tooth and lightly wipe it off with a moist, clean cloth to remove any debris. Ideally, the tooth should be placed in the child or parent’s cheek in an area where it won’t be accidentally swallowed or inhaled. (I know, pretty gross, but it is for the sake of your child). If this is too upsetting or you are afraid it will be swallowed, the tooth can be placed in a glass of milk.

You should immediately take your child to the dentist, ideally within the first 10 minutes of the occurrence. The dentist will likely try to place the tooth back into the socket once it is clean and lacking debris which might cause later infection. The tooth will then likely be splinted to the adjacent teeth for support, to help minimize movement. This support will help the tooth re-tighten back into the socket and is sometimes left for up to two to three weeks. The tooth will likely need a root canal since the nerve was severed, but this likely won’t be done for two or three days after.

If the tooth has been out of the mouth for longer than fifteen minutes, your child still needs to see the dentist immediately to avoid more complication or possible permanent loss of the tooth. Bring the tooth with you as mentioned above.

If you are far from the dentist, the tooth is clean and you feel that the tooth is intact, you can attempt to put it back in the socket yourself. Be sure that if you are going to attempt this, you place it in the correct way! The child should immediately be taken to the dentist for an evaluation. If the tooth cannot be found, the dentist may refer you to the emergency room for a chest x-ray to be sure that it has not been inhaled during the accident.

I won’t go into great discussion about the further treatment sequence in dealing with an avulsed tooth, as it is varies with the child and the extent of the injury. The biggest point being that you should take your child to the dentist immediately to avoid further complications which can be both emotionally and financially draining.

The other item I want to discuss is something called “Hank’s Solution” or “Hank’s Balanced Salt Solution.” This is a special liquid formulated by a scientist that is extremely compatible with living tissues and can help to stabilize an avulsed tooth until it can be placed back in the mouth. This solution is better than milk or any others that I am aware of and can help to increase the likelihood that the tooth will be successfully re-implanted. The only catch is that you have to have it before the injury happens! A great addition to your home first-aid assortment is the “save-a-tooth” kit. It Uses the specially formulated pH balanced solution, as well as a unique removable basket and net container that protects tooth root cells crucial to the success of the re-implantation process.

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

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

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

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

Images courtesy of Dr. Martin S. Spiller

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

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

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

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

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

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

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.