Children’s Dentistry page

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TwinsWhen should I first bring my child to the dentist?

The American Academy of Pediatric dentistry suggests that a child first be seen by a dentist when the first baby tooth erupts, or by the age of one year. At this visit, the parent holds the child on his or her knee while the dentist sits facing the parent knee to knee. While the child will not yet have all of his or her baby teeth in place by the age of one, a visual inspection allows the dentist to assess for the beginning of early childhood decay (Early Childhood Caries) and to council the parents on any obvious problems that appear to be developing. It also creates a record for the child and the parents.

Most childhood falls that result in injuries to the teeth happen between the ages of  two and three, while the child is learning to coordinate his movements.  In an emergency, parents are very glad to have the telephone number of a sympathetic doctor who already knows their baby.

Having said this, it is very rare to find a general dentist who will do an actual procedure, like a filling or an extraction on a child under the age of three. If it is absolutely necessary to do a procedure on a very young child, the general dentist usually refers to a pedodontist (a children’s dentist) who can sedate him or her, or an oral surgeon who can “sleep” the child.

Should the parent accompany the child into the operatory

The answer we learned in dental school was NO!!  Children always behave better without the parent in sight.

noParentsThe real answer to this question is: It depends entirely on the child (and the parents).

I have found that in a majority of cases, children do perfectly well with parents in the operatory.  It is the minority of cases that are the most difficult, and the ones in which the parents are best asked to leave for the waiting room.

The behavior of children in the dental setting depends largely on the child’s trust in an authority figure and his or her willingness to surrender control over his own body, even at the expense of minor pain, to an adult he does not know. Trust is a quality learned at home, on the playground and at school. Children who have learned that adults trusted by their parents are adults to be trusted by them are more likely to have better experiences at the office than those who have learned to distrust adults in general. Children who have been trained to expect adults to make good decisions on their behalf are more likely to have better experiences than those who tend to make all their own decisions at home.

In other words, if they run their home using behaviors they know makes their parents do what they want, they will try to do the same at the dental office where such behavior is inappropriate. Their inability to affect the dentist’s behavior in the same way they do their parents scares them, and the “bad experience” escalates from there. If a parent of one of these children is in the operatory, the child plays to the parent and the behavior only gets worse.

The child’s behavior is the variable that cannot be controlled by the dentist directly. It depends upon the factors discussed above, as well as things such as how much sleep the child got last night, the time of day of the appointment (mornings are always best), recent events in the child’s life, and the horror stories told to the child by his friends, siblings, and even his parents.

Should I bring my child to a children’s specialist?

Ian_in_chairWhile I, as a general dentist, treat a vast majority of children who come to my office, I never treat a truly uncooperative child. The work I do requires delicate movements that can’t survive the violence of an uncooperative patient. I never restrain a child. If he won’t let me do my job, I refer him to a pedodontist (a specialist who deals with children’s dentistry exclusively). Pedodontists have nerves of steel and soundproof operatories. Actually, that’s a half joke, but if they must spend a lot of time doing “behavior modification”, they can charge for the service, something which as a general dentist I cannot justify.

Pedodontists have special training in dealing with children’s dental problems, not just their behavior.  They are better equipped to perform simple interceptive orthodontic procedures on children without referral to an orthodontist.  General dentists refer patients to them all the time for problems peculiar to children, such as developmental difficulties and root canals on adult teeth that have not fully formed.  Some (not all) make use of hospital services to place very young children and others who are unable to cooperate under general anesthesia for doing general dental procedures.  This may be ideal for infants and very young children who must have teeth extracted.  Even though the extraction itself would be very easy for any dentist, the trauma of the procedure on an uncomprehending child could cause a fear of dentistry that could effect her for the rest of her life.

Why bother to fill baby teeth since they will all fall out anyway?

nursingbottoeNursing bottle syndrome (Early childhood caries).
For details, click on the images.

There are three very good reasons that baby teeth are just as important as adult teeth, and must be just as well protected from disease.

  1. Children need their teeth as much as you do to chew and smile.  If the teeth are allowed to become decayed, that child will suffer pain and an inability to eat properly which can lead to lifelong eating disorders, or at minimum poor nutrition for the time during which the child is unable to eat properly.  Children have social lives too, and the stigma of blackened stumps and bad breath can lead to derision (serious teasing) at school and at play, and could effect the child’s social development.

2. Bad baby teeth usually mean frequent visits to the dentist under very poor circumstances.  The child has not slept well, he is in a bad mood, and the dentist is the last person he really wants to see.  In addition, by the time they are seen, the dentist must usually remove the tooth, which is what the parents expect anyway.  So his visits always amount to painful episodes from which he emerges missing a piece of his body!  This sets the stage for not only bad behavior on succeeding dental visits, but for a person with a lifelong fear of dentists who will probably end up with dentures.

3. Finally, baby teeth are essential for holding the spaces open so that the adult teeth can come into the correct position when they are finally developed enough to erupt (“erupt” means to come through the gums for the first time)If certain of the baby teeth are removed before nature intended, the adult teeth that develop earliest will move into inappropriate positions crowding out the space necessary for the eruption of other adult teeth which develop at a later date.  This can lead to not only crooked teeth, but to real functional problems as well.  These involve chewing difficulties, TMJ problems, and pronounced facial asymmetries (this means that one side of the face develops more than the other side due to the differences in the way that the muscles on either side are used in chewing and grinding the teeth.)  A person gets two sets of teeth at different stages of life for very good reasons.  The adult version will not fit into a baby’s mouth, yet that child must still be able to chew food.  So while nature gave children a temporary set of teeth in order to fill a space that would otherwise have to remain vacant until age 12, she thought she might give them some extra work to do as well.

At what age should my baby’s teeth first erupt? (“erupt” means to “appear in the mouth”.)

decidErruptionScheduleThe baby teeth begin to erupt at about age 6 months and continue until about age 24 months at which time all 20 of the baby teeth should be in place.  In general, the teeth erupt from the front to the back, and the lowers come in about 2 to 6 months before the corresponding top teeth.  If your child is late, don’t worry.  They may finish as much as a year behind schedule.  If your child is missing one or more baby teeth, it does NOT necessarily mean that she will be missing the corresponding adult teeth.  If some of the baby teeth are discolored or misshapen, it does NOT usually indicate that there will be a problem with the adult teeth.

At what age should my child’s adult teeth erupt?

ErruptionScheduleYou should begin to see your child’s first adult teeth even before they lose their first baby teeth, at about age 6.  They are the first adult molars and they erupt behind the existing baby teeth.  They are yellow in the diagram above.  At about the same time the lower baby central incisors will loosen and fall out to allow the adult central incisors (blue) to erupt.  All the baby teeth should be gone, or the remaining ones lose by age 12.  The adult teeth that are forming under them will continue to erupt through age 17 or 18 when the wisdom teeth (white) finally are supposed to erupt. I say “supposed to” because many times they remain impacted and must be extracted.  This eruption schedule is not set in stone.  Some kids are just late bloomers and may be a year late in their eruption schedule.  Some may even be a year early.

How do adult teeth develop?

The three thumbnail images below show a clear plastic dentaform made by Kilgore International inc.  This dentaform shows the dentition of a child of about three years old.  The deciduous (baby) teeth are fully formed, fully erupted, and in occlusion (which means that the top teeth are in contact with the bottom teeth).  The roots of the baby teeth are clearly visible and approximately anatomically correct.  You can see the adult teeth just beginning to form in the plastic just above and below the roots of the baby teeth.  Click on any of the thumbnails below to see larger versions of all three images and more information on the formation of the adult teeth.

Tooth Development Chart Tooth Development Chart Tooth Development Chart


Click on the image above to see charts of how teeth develop

Interpreting a child’s panoramic x-ray


PedoPanoSmallAbove, you see a panoramic x-ray film of a child about 6 or 7 years old.  You can see the adult teeth forming underneath the baby teeth.  You see that the first molars (we call them the 6’s for 6 year molars) have erupted into place behind the last baby teeth in each arch, and so have the lower adult central incisors (you cannot see any lower baby centrals).  But the upper adult central incisors have not yet erupted into position (you cansee the upper baby centrals as little “stumps” sitting on top of the adult incisors). The adult second molars (the 12 year molars) are not expected to erupt until age 12.  They are shown here only partly formed behind the fully erupted six year molars

Why does my child grind her teeth at night?

We used to think that tooth grinding in children was perfectly normal. New research, however, has cast doubt on this old axiom. The grinding of the teeth during sleep in both adults and in children is now considered an indication that the patient may not be breathing correctly during sleep. Children tend to have extremely large tonsils and adenoids which may block the airway and in some cases cause the child to stop breathing for varying lengths of time during sleep. The name of the syndrome is Obstructive Sleep Apnea (OSA), and in children, this can be quite devastating. It has been linked to attention deficit hyperactivity disorder (ADHD) in children.

Of course not all children who grind their teeth at night suffer from OSA, but parents should be aware of the other symptoms that their child may display if they fail to breath properly at night. If your child suffers from one or more of the following symptoms in addition to night grinding, you should consult a pediatrician.

  • Behavioral and mental effects, include:
    • Excessive sleepiness during the day
    • Hyperactive behavior
    • Other behavioral disturbances
    • Decreased school performance
    • Mental retardation (in severe, untreated cases)
  • Cardiovascular effects, include:
    • High blood pressure
    • Pulmonary hypertension (High blood pressure in the lungs)
    • Abnormal heart function
  • Other health effects
  • Diminished growth due to reduced hormone production
  • Re-shaping of the ribs (due to increased respiratory effort)
  • Bed wetting
  • Worsening of coexisting medical conditions, including asthma.

What if the baby tooth fails to fall out?

lost_baby_tooth_orthoIn some cases, a baby tooth may remain in place even though the adult tooth is erupting beside it.  In this case, the baby tooth MUST come out one way or another or it will interfere with the positioning of the adult tooth.  The image above shows an adult premolar that has been forced to erupt out of the normal position it should occupy in the arch because of the presence of an over-retained baby tooth.  If the child cannot or will not remove it herself by wiggling it, then bring her in to see us for an extraction.

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