Tooth decay, also known as dental caries or cavities, is a breakdown of teeth due to acids produced by bacteria when they break down carbohydrates or sugar. It is the most common chronic infectious disease of childhood and can develop as soon as the first tooth comes in (early childhood caries or baby bottle tooth decay). Τherefore, it is absolutely necessary to establish healthy dental habits early in life.
Caries develops when a baby’s mouth is infected by acid-producing bacteria. Parents and caregivers can pass bacteria to babies through saliva. For example, bacteria is spread by sharing spoons or cups, testing foods before feeding them to babies, and cleaning off pacifiers into parents mouths.
Tooth decay also develops when the child’s teeth and gums are exposed to any liquid or food other than water for long periods, or frequently throughout the day. Oral bacteria break down the natural or added sugars contained in the liquid or food consumed, and in this way they produce to acids that dissolve the outer part of the teeth, causing them to decay. The most common way this happens is when parents put children to bed with a bottle of formula, milk, juice, soft drinks, sugar water or sugared drinks. It can also occur when children are allowed to frequently drink anything other than water from a sippy cup or bottle during the day or night. Milk should be served only with meals and not offered throughout the day, at nap time or at bedtime.
During the entire childhood and teenage years, it is absolutely necessary to avoid foods rich in sugar, as well as sugary snacks between meals. Desserts should be consumed after mealtime, and kids should be prompted to brush their teeth right after. In this way we have a lower risk of tooth decay, since the risk factor is the frequency, rather than the quantity of sugar consumption.
In our clinic, in order to make some children with severe tooth decay understand the problem and establish healthier habits, we apply the diet calendar. This is nothing else but a simple listing from the parent for some days, of whichever solid or liquid food (e.g. juice, milk) the kid consumes throughout the day, as well as the frequency of teeth brushing. Most of the times, even parents themselves are shocked with the bad quality of their children’s diet, and this becomes a starting point for healthier dietary and dental habits in the future.
Gingivitis is the mildest form of periodontal disease, often referred to as gum disease. It is caused by excessive plaque built-up. If plaque is not removed by daily brushing and flossing, it produces toxins that can irritate the gum tissue, which causes gums to become red and puffy, and easily bleed. If left untreated, gingivitis may pass to the next pathological level which is called periodontitis.
Many believe that periodontal disease only affects adults, but children can also develop it at any time in their youth. According to the statistics, the prevalence of gingivitis in developed countries is about 73% among children between 6 and 11 years of old, whereas in puberty gingivitis figures are varying from 50-99%. These numbers almost reach 100% during orthodontic therapy, since fixed orthodontic appliances impede the effectiveness of oral hygiene.
So, contrary to what parents tend to believe, gingivitis is a very common pathological condition of the gums in children and adolescents. Its signs and symptoms include:
1) Bleeding gums that regularly occur during or after brushing
2) Gum discoloration. Healthy gums are pink and firm, not are red, puffy and tender
3) Gums receding or pulling away from the teeth
4) Consistent bad breath that won’t go away
5) Loose teeth that are not caused by impact or any other force
The cause of gingivitis in children, teenagers and adults is the same; inadequate oral hygiene. It can be prevented by maintaining a healthy oral routine that includes brushing twice per day for 2-3 minutes at a time and flossing once a day. Moreover, eating a balanced diet and, of course, visiting the pediatrician dentist regularly, helps preventing gingivitis in this young age. This is the first major step in establishing periodontal health for the rest of the child’s life.
The use of fluoride for the prevention of caries has been an issue of extensive research for almost seven decades. Fluoride (F–) acts protectively against tooth decay in two ways; it helps weakened tooth enamel to rebuilt itself (remineralize) and on the same time it slows down its demineralization (loss of minerals from tooth enamel). In these ways it can reverse the early signs of tooth decay. Moreover, it acts against the bacterial plaque on the tooth surface preventing the growth of harmful oral bacteria.
Mineral fluoride can be found in small concentrations in foods that we consume daily, like cucumber. In some countries, fluoride has been added to the public water supply, as a measure to reduce tooth decay. Water fluoridation seems to reduce dental caries at a percentage that reaches 35% in baby teeth. However this finding is controversial; some other studies show that this measure in industrialized countries may be unnecessary because topical fluorides (such as in toothpaste) are widely used and caries rate have become low. In this perspective, and in order to avoid the side effects of overexposure to fluoride (i.e. dental fluorosis), most European countries (97-98%), including Greece, have chosen not to fluoridate drinking water.
Children can enjoy the beneficiary effects of fluoride at home first of all by using a fluoride tooth paste. According to the latest directions of WHO, the use of fluoride tooth paste may start from the age of 6 months. Up to the age of 6 years, tooth paste should contain 1000ppm F–, whereas for older children 1450ppm F–. The quantity of toothpaste for children under the age of 3 should be at a minimum, in other words, a trace on the surface of the toothbrush, while for older children it should initially have the size of a lentil and after the age of six, the size of a small pea. Another possible source of fluoride at home is a fluoride mouth rinse. This is recommended for children older than the age of 6-7 years, who do not run the risk of shallowing it, and of course it should be used according to the pediatric dentist’s instructions.
In-office fluoride treatments are performed with fluoride preparations with a much stronger concentration than that of toothpastes or fluoride mouth rinses. Professional fluoride treatments generally take just a few minutes. The fluoride may be in the form of a solution, gel, foam or varnish. Typically it is applied with a cotton swab or brush, or it is placed in a tray that is held in the mouth for several minutes. Depending on the child’s oral health status, fluoride treatments may be recommended from the age of 4 every three, four, or 6 months.
The chewing surface of posterior teeth has pits (small ‘holes’) and fissures (grooves). These areas withhold bacteria and remnants of food, resulting in tooth decay at a percentage of up to 50% in school-aged children.
Sealants are a simple preventive method against pits’ and fissures’ cavities. They are transparent or semitransparent liquid resins, placed on the chewing surfaces of posterior teeth in order to cover their pits and fissures. Placement is fast, there is no need for local anesthesia, and it can be completed in one visit. Their effectiveness in reducing the risk of decay in molars has been shown to be nearly 80%.
The first sealants can be placed on first permanent molars that emerge in the age of 6-7 years and then, as the child grows, sealants can be placed on the other emerging posterior teeth. Their average duration is four years; however, if placed properly and the child has a good oral hygiene, sealants can last longer.
- Oral hygiene of the baby should start right after the first tooth’s eruption. Parents or caregivers should wipe the baby’s teeth with a wet gauge twice a day, in the morning after the first feeding and right before bed, to wipe away bacteria and sugars.
- After the first year, teeth should be brushed 2-3 times a day with a soft, small-bristled toothbrush and a fluorine tooth paste.
- Before the age of 6 years, tooth paste should contain 1000ppm of fluoride (F–), while for children older than six, its fluoride content should be
- The quantity of toothpaste used should be a thin trace on the surface of the toothbrush until the age of 3 years, whereas for children aged 3-6 years it should have the size of a lentil and after the age of 6, the size of a small pea.
- Until the age of 8 years, the child is not capable of following complicated brushing techniques, and for this reason, simple horizontal movements from front to back are recommended.
- Until the age of 8 years, the effectiveness of brushing by the child alone is poor, and therefore supervision by the parents is necessary.
- After the age of 8 years, the use of dental floss is recommended for cleaning the interdental spaces that can not be reached by the toothbrush.
The charts show when primary (baby) and permanent teeth erupt (come in) and fall out. This is a general guide, since eruption times vary from child to child; small deviations of one to two months for temporary teeth and one to two years for permanent teeth should not worry us.
The first baby teeth to break through the gums are usually the two bottom central incisors (the two bottom front teeth), at an age that can vary from 6 months up to 18 months. The first permanent teeth to emerge are in some children the first molars, in some other children the lower front incisors (lower front teeth). This usually happens in the age of 6-7 years, but in rare cases first permanent teeth don’t emerge until the age of 8. By the age of 13, most of the 28 permanent teeth will be in place. Finally the third molars or wisdom teeth emerge between the ages of 17 and 21, bringing the total number of permanent teeth up to 32.
Tooth and gum injuries are very common in children, especially between the ages of 1-3 and 8-10 years old. Parents should keep in mind that every tooth injury, even if there is not an apparent problem, is a condition that has to be directly evaluated by a pediatric dentist, since its consequences may appear later in life, sometimes after many years.
Injuries to primary teeth usually happen at 2 to 3 years of age, when motor coordination is developing. They include fracture, displacement, and avulsion (complete displacement of the tooth from the socket). In any case, pediatric dentist’s main concern is to insure that the dislocated primary tooth will not cause any damage to the developing permanent one. Until visiting the pediatric dentist, parents should never attempt to put back a dislocated or an avulsed primary tooth to its position. All primary teeth injuries have to be evaluated and, if necessary, treated. Otherwise we run the risk of abscess formation at the tip of the primary tooth’s root, which may affect the formation and the eruption of the pemanent tooth that will replace it.
To sum up, an injured primary tooth needs immediate evaluation and treatment if necessary, constant clinical and radiographical follow-up, and even extraction if the eruption of the permanent tooth may be affected. Parents should call the pediatric dentist promptly and never attempt to reposition the dislocated or avulsed baby tooth.
Injuries to permanent teeth include fractures, extusion, intrusion, lateral luxation and avulsion. They are more serious injuries, since permanent teeth have to be maintained by all means. In case of a tooth fracture, the displaced tooth part has to be kept in normal saline or milk, until the visit to the pediatric dentist, who will attempt to put it back to its position. If the permanent tooth is displaced, intruded or extruded, it should be immediately treated by the pediatric dentist in order to prevent pulp necrosis and abscess formation. Finally, in case of avulsion (complete displacement of the permanent tooth from the socket), parents should follow the instructions below :
- Locate the tooth.
- Wash it with cold water without touching its root.
- Place the tooth back to its place and keep it stable with a gauze.
- If you can not put is back to its place, place the tooth in cold milk
- Contact immediately the pediatric dentist.
We should point out once again that injured teeth need a close monitoring, sometimes for years postinjury. Consequences of a trauma may be long-term, even on teeth that were not apparently hurt. The pediatric dentist is trained to evaluate the injured teeth, intervene when necessary and determine the frequency of recall visits. On the contrary, a general dentist who doesn’t have special knowledge on trauma is very difficult to evaluate the situation, choose the best treatment and monitor the case, sometimes with very negative results for the maintenance of some teeth in the jaw.
Athletic mouth guards are devices that protect the teeth and soft tissues of the mouth during sports. Children that are in greater risk are those who play contact sports such as basketball, football, boxing, martial arts, ice hockey. But even those who participate in non-contact sports -such as gymnastics- , or recreational activity -such as skateboarding or mountain biking-, can benefit from wearing a protective mouthguard.
There are many advantages to using a mouth guard. They help to limit the risk of mouth-related injuries to the child’s lips, tongue and soft tissues of the mouth. Mouth guards also help children avoid chipped or broken teeth, nerve damage to a tooth, or even tooth loss. They also may reduce the severity of concussion in sports, because they help distribute forces from a blow to the head. A mouth guard is particularly important for children who wear braces, since an injury to the face could damage brackets or other fitted appliances and cause greater injury to the lips and soft tissues.
There are two types of mouth guards, prefabricated and custom made ones. Prefabricated mouth guards can be bought at most sporting goods stores. Best of those are the ‘boil-and-bite’ mouth protectors. They are made from thermoplastic material that is placed in hot water to soften, then in the mouth and shaped around the teeth using finger and tongue pressure. The disadvantage of prefabricated mouth guards is that they don’t offer the best fit, thus the best protection, and can be uncomfortable. On the contrary, custom-fitted mouth protectors are individually designed and made in a dental office or a professional laboratory. They are more expensive but provide the best fit, protection and comfort.
1. When should I first take my child to the pediatric dentist?
Even if it sounds extreme, it is not a bad idea to visit the pedodontist before the child’s first birthday. The main goal of this first visit is to be informed about healthy dental habits including oral hygiene, healthy diet and the effects of various habits like the bottle, finger sucking and the pacifier. If everything is alright, next visit should be scheduled around the age of 3.5 to 4 years old. This is the perfect age for the kid to get familiar with the dental environment, cooperate, and establish good oral hygiene habits. This is also the age when in-office teeth fluoridation for caries prevention is initiated.
2. In case of a delay in the eruption of baby teeth, will there be a delay in the eruption of the child's permanent teeth too?
No. Contrary to what is believed, there is no scientific research that correlates the age of baby teeth eruption with the age of permanent teeth eruption.
3. My son's permanent teeth emerge very late compared to his classmates. Does this mean something for his growth?
No. A deviation of 1-2 years for the eruption of permanent teeth is normal and should not be concerning. Gender plays here an important role; permanent teeth eruption in boys happens usually later than in girls. However, in case of a serious delay, you should consult a pediatric dentist.
4. My child’s two lower front permanent teeth emerged behind the primary ones. Is this normal?
Yes. The two lower central incisors are usually the first permanent teeth that erupt right behind their corresponding baby teeth, which in most cases are moving and finally fall on their own. Even though the eruption position of the permanent front lower incisors is lingual (i.e. facing the tongue), when the baby teeth fall out, the permanent ones are being pushed by the tongue to their final front position. Not rarely, however, the permanent lower incisors are emerging much more lingually than normal, literally behind the baby teeth, which are not moving at all. In these cases, a visit to the pediatric dentist is necessary in order to remove the baby teeth, so as to create space for the permanent ones to replace them.
5. My child's permanent teeth are yellow. Is this normal?
Yes. Permanent teeth are always darker and a bit more yellow than the shiny white baby teeth, especially when they erupt next to them. This is absolutely normal due to their composition. A dark yellow color, however, may be due to an intense presence of bacteria on teeth surfaces (plaque or tartar), or to an anomaly in the formation of teeth substances, which needs further investigation and special care.
6. My 7-year old son has a decayed baby molar. Why should it be restored since it is going to be replaced anyway?
This is a very common question among parents, especially until a decayed baby tooth shows symptoms. This perception is totally wrong, though. Primary teeth health is really important, even though they will be replaced. Healthy baby teeth are necessary for chewing and speaking correctly, contribute to the normal growth of the jaws and the face, maintain the place needed for the eruption of the permanent teeth and, last but not least, offer a nice big smile and boost the confidence of the child. On the contrary, decayed baby teeth can affect the child’s general health (bad mood, pain, fever).
7. My child was hurt and one front tooth has changed color. Should I worry?
Tooth discoloration after a dental injury is common and may happen immediately or after a longer period postinjury. In the first case, tooth discoloration is caused by the irritation of its pulp by the injury, so it slowly subsides and the color is restored. On the contrary, belated tooth discoloration indicates a more serious injury in which dental pulp is necrotic and needs treatment. If the tooth is left untreated, it may form a pimple with pus discharge (fistula) on its gum. In any case, every dental injury should be considered as a serious situation, which should prompt the parents directly to the pediatric dentist, in order to evaluate the vitality of the tooth clinically and radiographically.
8. My 6-year old daughter has dental problems but does not cooperate with the dentist. She was reffered to the children's hospital for general anesthesia, but I am thinking about letting her grow and fix her teeth later. What do you think?
A child may not cooperate with the dentist for several reasons, like fear, anxiety, previous bad experience, very young age or health problems. The pediatric dentist is a specialist that has the knowledge and the means to overcome these obstacles and ensure the child’s cooperation. This is the reason why we propose that visits to the pediatric dentist should start at the age of 3-4, so that the child becomes familiar with the clinical environment and establish healthy dental habits early in life. However, if a child’s cooperation even with a pediatric dentist is impossible, then dental treatment should be carried out in a hospital under general anesthesia. In the opposite case, when parents decide to postpone their child’s treatment hoping for better days, cooperation problems usually remain or even get worse, and dental problems will multiply.
9. My daughter grinds her teeth in her sleep. Should I worry?
No. Many school-aged children grind their teeth while sleeping. The cause of teeth grinding is in most cases not known; stress or increased ear pressure are considered to be risk factors. Usually this bad habit stops automatically, but if it continues after the age of 12 years, it has to be evaluated by the pediatric dentist.
10. My 3-year old daughter sucks her finger in her sleep. Will this cause a possible dental problem?
Possibly. The intensity, the frequency and the duration of this bad habit may affect the position of the teeth and the growth of the jaws. Its consequences include crowding of the front teeth, narrowing of the upper jaw with a very high palate and positioning of the tongue between the upper and the lower jaw, thus creating a gap between the teeth when the child closes his mouth (open bite).
Most children stop sucking their finger at the age of four. However, if the habit insists after the age of five, the pediatric dentist will advise and encourage the child to stop and in some cases a special orthodontic apparatus will be applied.