Introduction

Pediatric Dentistry is a dental specialty that focuses its attention on infants and children providing preventive and therapeutic oral health care. During the "growth" phase of a child, special approaches are needed to guide the dental growth and development in order to avoid future dental problems. Every child deserves a healthy start in life, but when it comes to oral health, many children face significant challenges. Over 40% - 50% of children are affected by tooth decay before age 5.

A common question that parents ask is “why spend on the maintenance of milk teeth when they are to be finally replaced by the permanent ones?”

Milk teeth are as important as the permanent ones because:

  • Baby teeth are important in proper feeding and nutrition.
  • Milk teeth serve as space maintainers for the proper spacing and alignment of the permanent teeth.
  • Healthy milk teeth are crucial in helping the baby learn how to speak properly.
  • Neglect of the baby teeth can result in pain, infection of the gums and jaws, impairment of general health, and premature loss of teeth, which is a major cause of orthodontic problems.
  • Care of the primary teeth is important to prevent dental decay and to encourage proper nutrition as well as ensure a future of healthy permanent teeth.

Infant Oral Care

Tooth Eruption

Some babies are born with neonatal teeth (teeth that develop in the first month) that require a visit to the dentist for their removal.

The 20 baby teeth are already forming before birth. A baby's front four teeth usually erupt first, typically at about 6-8 months of age, although some children do not have their first tooth until twelve months old. The rest of the twenty baby teeth appear in pairs along the sides of the jaw until the child is about 3 years old. The first permanent teeth begin to erupt at about age 5-6, starting with the first molars and lower central incisors. This process will continue until approximately age 13 to 14 excluding the third molars (wisdom teeth). The third molars usually erupt at around age 21.

It is not uncommon that some teeth are a few months early or late as all children have different eruption patterns.

Teething

When teeth begin erupting, babies may have discomfort and can be irritable. They like to place fingers and other objects in mouth to relieve discomfort. Also, babies may have sore or tender gums. Some babies can have increased dribbling, flushed cheeks and changed eating patterns. You can also give your baby teething gel, cool teething ring or cold wet washcloth to chew on, but never dipped in sugar or syrup. If your child is still uncomfortable, consult your dentist or physician.

Fever is not normal for a teething baby. If your infant has an unusually high or persistent fever while teething, see your medical doctor.

Tooth Brushing

Wipe infant's teeth gently with a moist, soft cloth or gauze square at least twice a day, especially before sleeping. As babies grow, use a child's extra soft toothbrush with water or a very small amount of non-fluoridated toothpaste. Fluoride containing toothpaste should only be used when your child can spit.

By age two or three begin to teach your child to brush. You will still need to brush where they miss. When children are seven to eight years old they are usually able to brush on their own. Flossing can be more challenging and this skill develops around age of nine. Gently brush the tongue to remove debris, floss between teeth daily.

Feeding

Avoid putting your baby to bed with a bottle, sippee cup or while breastfeeding. This habit may cause cavities when your baby has teeth especially if milk, formula, juice or other sweetened liquid is used. Only water should be put in a bottle or cup if your child cannot fall asleep without it. While your baby is breastfeeding, wipe the teeth with a damp washcloth as soon as he or she falls asleep and stops sucking. Sharing items such as spoons, pacifiers, toothbrushes and toys can spread cavity-causing germs between caregiver and baby and between babies themselves. Regular feeding is important for nourishment to allow baby to grow strong and healthy. Continuous use of bottle for comfort rather than feeding can cause damage on teeth. Never put baby to bed with bottle because teeth can be damaged as the liquid pools in the mouth feeding the bacteria for most of the sleeping time. Liquid can also seep into the middle ear tubes causing irritation and possible ear infections.

If use bottle for baby under 12 months, put only breast milk, formula or water in it. The bottle should be taken away once feeding is finished. Introduce a feeding cup to child at 6 months which helps to discourage an attachment to the bottle and wean off the bottle by 12 months. Drinking juice from a bottle should be avoided. When juice is offered, it should be in a cup. At will night time breastfeeding should be avoided after the first baby teeth begins to erupt. Nursing continuously from breast during nap or night time can increase decay risk.

Dental Treatments

Pit and Fissure sealants

The chewing surfaces of teeth are never flat. They have infact certain depressions called Pit and Fissures which serve as potential traps for food and bacteria making the teeth susceptible for decay. Although other factors such as dietary habits, oral hygiene and amount of sugar intake do pay an important role but the pits and fissures have been suggested as " the single most important anatomic feature leading to the development of tooth decay". Therefore as a preventive measure certain pits and fissure sealants are placed.

The decay inhibiting properties of sealants are attributed to the physical obstruction of the pits and grooves. This prevents penetration of fermentable sugars and the bacteria cannot produce acid that causes tooth decay. The safety and effectiveness of pit and fissure sealants as a decay preventive measure has been confirmed by the American Dental Association. These are contraindicated in cases of already existing decay which require filling.

Not every tooth requires sealant. The natural flow of saliva usually keeps the smooth surfaces of teeth clean but does not wash out the grooves and fissures. So, the teeth which are most susceptible to decay will benefit most by sealants.

Restorations

Amalgams or silver fillings are used to restore decayed areas in teeth. They have a scientifically proven history of safety and effectiveness in restoring teeth. The problem associated with its use is the recent upsurge in public opinion concerning its health safety. It is NOT evident that use of amalgam in children's teeth causes health problems.

Composites / Glass Ionomer or white fillings are used to restore fractured and/or decayed teeth, especially for front teeth in which cosmetic appearance is important. The shade of the restoration material is matched as closely as possible to the color of the natural tooth.

Stainless steel crowns are silver colored "caps" used to restore teeth that are too badly decayed or grossly broken, primary molars that have undergone pulp therapy, and primary or permanent teeth with enamel defects.

Composite resin strip crown is the best choice in restoring extensive decayed or broken baby front tooth. It provides a good esthetics and durable restoration.

Pulp Therapy – “Children’s root canal”

Pulp therapy is the treatment of infected nerves and blood vessels in teeth. With the proper pulp treatment, the tooth can be preserved for chewing food and maintaining proper space for permanent teeth.

Extensive dental decay and traumatic injury are the main reasons for a tooth to require pulp therapy. The two common forms of pulp therapy in children's teeth are the pulpotomy and pulpectomy.

A pulpotomy removes the diseased pulp tissue within the crown portion of the tooth, followed by the placement of medicine to prevent bacterial growth and to calm the remaining nerve tissue. This is followed by a final restoration (usually a stainless steel crown). Tooth extraction is avoided.

A pulpectomy is required when the entire pulp of the tooth is dead. The diseased pulp tissue is completely removed from both the crown and root. The canals are cleansed, disinfected and in the case of primary teeth, filled with a resorbable material. Then a final restoration is placed. A permanent tooth would be filled with a non-resorbing material.

Extractions

Extractions (remove the tooth) are done only as a last resort. If a primary molar is removed prematurely, a space maintainer will be placed. Some extractions are needed for orthodontic reasons to help facilitate tooth alignment.

Space Maintainers

Space maintainers are used when a baby tooth has been prematurely lost (dental disease or trauma) to hold space for the permanent tooth. A space maintainer helps to prevent future space loss and dental problems.

If a baby tooth is lost too soon, the teeth beside it may tilt or drift into the empty space. Teeth in the other jaw may move up or down to fill the gap. As a result, lack of space in the jaw for the eruption of permanent teeth. So, permanent teeth are crowded and come in crooked. If left untreated, the condition may require extensive orthodontic treatment.

Space maintainers are appliances made of metal that are custom fit to child's mouth. They are small and unobtrusive in appearance. Most children easily adjust to them after the first few days. Space maintainers hold open the empty space left by a lost tooth and prevent movement of the remaining teeth until the permanent tooth takes its natural position in the jaw.

Space maintainers need special care. Sticky sweets or chewing gum should be avoided. Do not tug or push on the space maintainer with your fingers or tongue. Also, keep the space maintainer clean with conscientious brushing and flossing. Regular dental visits are needed to monitor the space maintainer. The space maintainer can be removed when the permanent tooth closes to eruption.

Early Childhood Tooth Decay

Baby Bottle Tooth Decay (Nursing Bottle Caries): The term describes a dental condition which involves the rapid decay of many or all the baby teeth of an infant or child. The teeth most likely to be damaged are the upper front teeth since they are the first teeth to erupt and thus have the longest exposure time to the sugars in the feeding bottle. The lower front teeth tend to be protected by the tongue as the child sucks on the nipple of the bottle or the breast.

Baby Bottle Tooth Decay is caused by long exposure of a child’s teeth to liquid containing sugars generally when the baby falls asleep with a bottle containing milk or juice or a pacifier dipped in honey. The liquid pools around the front teeth. During sleep, the bacteria living in every baby’s mouth, turns the milk sugar or other sugars to acid which causes the decay.

By the time the condition is noticed by the parents it may be too late and extractions of the decayed teeth may be necessary. As a result, your child may suffer from long term disorders which include speech impediments, possible psychological damage, crooked or crowded teeth, and poor oral health.

The condition can be easily prevented by

Fluoride

Fluoride is a natural mineral and is one of the most effective agents for preventing tooth decay and making your teeth strong. Fluoride can be found in water and in many different foods, as well as in dental products such as toothpaste, mouth rinses, gels, varnish and supplements. Fluoride is effective when combined with a healthy diet and good oral hygiene.

Does my child get enough fluoride?

The best way for your child to receive fluoride's protection is by drinking water containing the right amount of the mineral. Children who from birth drink water containing fluoride on average have up to 50% fewer cavities. Your dentist considers many different factors before recommending a fluoride supplement if you live in a community that does not have optimally fluoridated drinking water. Your child's age, risk of developing dental decay, and the water and different liquids your child drinks are important considerations to ensure your child is receiving the proper amount.

Fluoride supplements (drops or tablets) are no longer recommended to all children because of the risk of fluorosis.

Children who benefit the most from fluoride supplements are those at highest risk for dental decay. Risk factors include a history of decay, high sugar diet, orthodontic appliances and certain medical conditions.

What type and amount of toothpaste should a child use?

Fluoridated toothpaste should be introduced when a child is 1 year of age. Prior to that parents should clean the child's teeth with water and a soft-bristled toothbrush. When toothpaste is used in young children, parents should supervise brushing and only a small pea-sized amount on the brush are recommended. Children should spit out and not swallow excess toothpaste after brushing. Do not leave toothpaste tubes where young children can reach them. The flavors that help encourage them to brush may also encourage them to eat toothpaste.

If your local water supply is NOT fluoridated:

Birth - 12 months: As soon as teeth appear, clean them twice daily with a child soft toothbrush without toothpaste.

12 months - 6 years: Clean teeth twice a day with low fluoride toothpaste (Colgate My First, Oral B stages, MacLean's Milk Teeth) 6 years and over: Clean teeth twice a day with standard fluoride toothpaste.

If your local water supply is fluoridated:

Birth - 18 months: As soon as teeth appear, clean them twice daily with a child soft toothbrush without toothpaste.

18 months - 6 years: Clean teeth twice a day with low flouride toothpaste (Colgate My First, Oral B stages, Macleans Milk Teeth) 6 years and over: Clean teeth twice a day with standard fluoride toothpaste.

Is fluoride safe?

Fluoride is documented to be safe and highly effective in caries prevention. Research indicates water fluoridation, the most cost effective method in caries prevention. Only small amounts of fluoride are necessary for the maximum benefit.

Excessive fluoride ingestion by young children can lead to dental fluorosis, which is a chalky white to even brown discoloration of the permanent teeth, usually on the front teeth. Many children often get more fluoride than their parents realize. Being aware of a child's potential sources of fluoride can help parents prevent the possibility of dental fluorosis.

  • Too much fluoridated toothpaste at an early age.
  • The inappropriate use of fluoride supplements.
  • Hidden sources of fluoride in the child's diet.

Young children may not be able to spit out fluoride-containing toothpaste when brushing. As a result, they may ingest an excessive amount of fluoride during tooth brushing. Toothpaste ingestion during this critical period of permanent tooth development is the greatest risk factor in the development of fluorosis.

Excessive and inappropriate intake of fluoride supplements may also contribute to fluorosis. Fluoride drops and tablets should not be given to infants younger than six months of age. After that time, fluoride supplements should only be given to children after all of the sources of ingested fluoride have been accounted for and upon the recommendation of your dentist.

Certain foods and drinks that are manufactured in fluoridated cities can contain high level of fluoride. This is another source of fluoride if it is in the foods or drinks.

Apart from fluoride, any other agents can help to prevent decay in children's teeth?

Chlorhexidine is an antiseptic that is commonly used in mouthwashes. Chlorhexidine gel has been commonly used and is documented safe for caries control in children. The gel (pea-sized amount) is brushed on the teeth either once a week or daily.

"Tooth Mousse" Casein phosphopeptide stabilised amorphous calcium phosphate (CPP-ACP) is a new form of calcium phosphate developed whereby the calcium and phosphate ions (teeth minerals) are held in a bioavailable form using milk protein casein phosphopeptides. This CCP-ACP can help to slow down decay progression and promote regression of early stages of decay. It is available in creme in a variety of flavours (GC Tooth Mousse) or in a sugar-free chewing gum (Recaldent).

Oral Habits

Frequently children acquire certain habits that may either temporarily or permanently be harmful to teeth and tooth supporting structures. These habits are acquired as a result of repetition. In the initial stages there is a conscious effort to perform the act. Later the act becomes less conscious and if repeated often enough may enter the realms of unconsciousness.

Some common oral habits seen in children include thumb sucking, mouth breathing, tongue thrusting, lip biting, grinding of teeth and nail biting.

Thumb / finger sucking habit

It is completely normal for babies and young children! Sucking is a natural reflex and infants and young children may use thumbs, fingers, pacifiers and other objects on which to suck. It may make them feel secure and happy or provide a sense of security at difficult periods.

Prolonged thumb / finger sucking habit can create dental problems such as crooked teeth and bite problems. The severity of the dental problems depends on the frequency, duration, intensity and position of the thumb / finger in the child's mouth.

Most children stop sucking habits on their own between the ages of 2-4. Children should cease thumb sucking by the time their permanent front teeth are ready to erupt (age 6-7) to avoid associated dental problems.

Pacifiers are no substitute for thumb sucking. They can affect the teeth essentially the same way as sucking fingers and thumbs. If you have concerns about thumb sucking or use of a pacifier, consult the pediatric dentist.

Tips for breaking child's thumb / finger sucking habit:

Instead of scolding children for thumb sucking, praise them when they are not.
Children often suck their thumbs when feeling insecure. Focus on correcting the cause of anxiety, instead of the thumb sucking.
Reward children when they refrain from sucking during difficult periods.
Pediatric dentist can encourage children to stop sucking and explain what could happen if they continue. Parents need to be supportive.
If these approaches fail, remind the children of their habit by bandaging the thumb or putting a sock on the hand at night. Your pediatric dentist may recommend the use of a mouth appliance that discourages sucking habits.

Tooth Enamel Defects

Enamel defect can be implicated as "weak" enamel with reduced thickness or enamel with poor quality. Enamel defect can appear as pitted, rough surfaces or with white, yellow or brownish discolouration in a tooth or in multiple teeth.

Enamel is a protective layer on the visible part of the crown of the tooth. It is the hardest and most highly mineralized substance of the body. The formation of enamel is very sensitive, any disturbances occur during the tooth development can result in enamel defects, affecting the primary or permanent teeth.

What causes enamel defects?

There are many different risk factors have been linked to enamel defects in primary and permanent teeth in children. The most common risk factors include:

  • Mother's health during pregnancy (illnesses, diet deficiency)
  • Prematurity
  • Birth difficulties
  • Medications given to mother prior birth or to child during early childhood
  • Early childhood diseases (high fever, pneumonia, middle ear infection, viral infections etc.)
  • Chronic / frequent childhood illness during first four years of life
  • Poor childhood nutrition (deficient diet, lack of calcium, phosphate, vitamins A, C, D)
  • Trauma to mouth or primary teeth can cause localized enamel defects

Rarely, enamel defect can be inherited and is called Amelogenesis Imperfecta. Every primary and permanent totoh has abnormal enamel formation.

What are the dental problems as a result of enamel defects?

  • Affected teeth can be fragile and may wear or lose enamel easily
  • Increase risk of dental decay
  • Tooth sensitivity from hot and cold foods and drinks if the underlying dentine layer is exposed
  • Socially, child may feel embarrassed to smile

What are the treatment options for enamel defects in children?

  • Fluoride treatment (gel, rinse, remineralising cream)
  • Restoration includes direct tooth coloured restoration, facing or crown, stainless steel crown.
  • Extraction for very badly formed and decayed teeth followed by orthodontic management

Early Orthodontic Treatment

As child grows, his/her teeth may not develop into normal position and biting relationships. Early orthodontic treatment allows minor tooth movement which guides the teeth as they emerge in the child's mouth. This type of treatment may include fixed or removable appliances, spacers, and/or braces. Early treatment may have the benefit of eliminating or minimizing the need for additional treatment later in life.

Malocclusion (crowded or crooked teeth or bite problems) is often inherited. Orthodontic problems also are caused by dental injuries, early loss of baby teeth or oral habits (e.g. thumb sucking).

It is recommended that children should receive their first orthodontic evaluation by age 7, which allows early identification of potential problems. Certain orthodontic conditions are also best treated at this age. Full braces are placed after most of the permanent teeth erupt (Age 12).

Early orthodontics can straighten crooked teeth, guide erupting teeth into position, correct bite problems and can prevent the need for tooth extractions. The result of straight teeth can give a more beautiful smile in your child and teeth are easier to keep clean and less susceptible to dental decay and gum disease.

Special care is recommended during orthodontic treatment. Careful brushing and flossing keep the appliance and child's dental health excellent. Removable appliances should be brushed each time the teeth are brushed. Besides, the orthodontic appointments, regular check ups are required to protect child from dental decay and gum disease. Child can eat a normal diet during orthodontic treatment, except sticky foods (chewing gum, caramels) and large, hard foods (peanuts, chips, popcorn). Some appliances alter speech, but most children adapt quickly and speak clearly within few days. Generally, children can safely play with an orthodontic appliance.

Like other dental treatment, orthodontic treatment requires good compliance from the child to achieve the desired outcome.

Dental Trauma Emergencies

When your child's baby tooth is knocked out, contact and see your dentist as soon as possible.

If a permanent tooth is knocked out, gently rinse tooth under water and do not scrub the tooth. Replace the tooth in the socket if possible and hold it there with clean gauze or a wash cloth. If the tooth cannot be placed back in socket, place the tooth in a glass of milk, saliva or water and come to the dental practice immediately. Time is critical in saving a traumatic tooth. The faster you act, the better your chances of saving the tooth.

If the tooth is chipped or fractured, the quicker you act, the better your chances of preventing infection and reduce the need for extensive dental treatment. Rinse the mouth with water and apply cold compresses to reduce swelling. If you can find the broken tooth fragment, bring it with you to the dentist.

If child has head injury or jaw fracture as a result of the accident, go immediately to the emergency room of hospital. Head injury can be life threatening.

Dental injuries can be prevented in sports by wearing mouth guards.

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