Children’s Dentistry page

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TwinsThumb sucking

Thumb sucking is perfectly normal for infants.  Most children stop sucking their thumb by the age of two.  If he or she does not, parents should try to discourage the habit by the age of four.  Thumb sucking actually places forces on the bone that supports the teeth and causes it to grow outward and upward causing an anterior “open bite” and sometimes a narrow upper arch form.  These deformities are easily diagnosed by any dentist or hygienist.  As a rule, the bony abnormalities will correct themselves when the habit is stopped, as long as it is stopped by about the age of six.  If the habit persists after the age of six, most of the time the only correction is by means of orthodontics (braces).

Dentists deal with this problem by building a simple habit breaking device, but these devices only work if the child truly wants to stop sucking his or her thumb.  By the time children begin to interact with others of their own age, the thumb habit becomes a social liability, and the child really does want to stop, but may need a bit of help.  The appliance acts as a reminder to keep the thumb out of the mouth, and also prevents the child from being able to create a suction between the thumb and the roof of the mouth.  This suction feels good and is an important factor in keeping the habit active.

While removable appliances are available, children have a habit of losing or breaking them.  Most dentists recommend an appliance which is permanently cemented to the upper molars.  They consist of two orthodontic bands for the molars with a thick wire running between them.  Most have a button of smooth plastic which sits in the indentation in the roof of the mouth where the thumb is placed during the sucking habit.

Will my child need braces?

Many times, children come in with congenital deformities (ones that they are born with) or developmental problems (ones that are caused by other factors like thumb sucking or other habits, and some, like crowded teeth that are the result of genetic factors but are not present at birth).  Many of these problems are not apparent to the parents, and require a dental exam to identify them.  Most of the common ones are covered in my section on orthodontics.  Left untreated, these deformities cause the child lots of functional and esthetic problems in the years ahead.  It is essential that all children be examined for orthodontic deformities by about the age of 7 when the most common skeletal deformities can most easily be treated.

The ugly duckling stage

One stage of development needs special comment because so many parents mistake it for an orthodontic problem.  It’s called the “ugly duckling” stage when there is a space between the top central incisors.  This is the norm between ages 7 through 12 years of age, and usually is not connected with a permanent space between the teeth.  The condition is well diagramed below.


ugly_ducklingUglyDucklingSpace Maintainers

spaceMaintainerIf your child loses certain of his baby teeth too early, usually due to decay, it is likely that he will need  orthodontic help to reclaim the space lost due to the forward migration of the six year molars into the space which was reserved for the second premolar.  If a dentist is able to catch this situation before too much migration has taken place, he can build a “space maintainer to keep the first molars from drifting forward.  It might look like the one in the diagram to the right, or it might connect both adult first molars with a wire that lies against the insides of all the front teeth in the arch.

Why do my children keep getting new cavities all the time?

For years, it was never really made clear that “the cavity prone years” as we called them in the years before the health benefits of fluoridation began to kick in, are really just the years when kids discover the wonders of sweet foods and drinks.  High sugar intake throughout the day means lots of tooth decay.  The end of the cavity prone years always coincided with the time when the child began to mature and lose his taste for sugar.  It’s as simple as that.  The less sugar, the less decay.  Oral hygiene is certainly important because the germs in plaque are responsible for transforming sugar into the acid that is ultimately responsible for the decay, but without the sugar, the germs have no raw materials to create the acid in the first place .  Please click on the icons below for a thorough understanding of how sugar, germs and hygiene interact to influence the state of health in anyone’s mouth, kids included.

Tooth Decay
Dental Hygiene
Healthy Teeth
What are Nice Teeth



Children’s oral hygiene

At what age should they start to brush?

Very young children usually want to imitate their parents.  The easiest way to indoctrinate children in brushing is to let them watch you do it on a regular basis and then encourage them to imitate you when they show an interest.  Technique is not important at an early age.  Healthy children are not susceptible to gum disease, and if they are not eating too much sugar, the presence of some plaque left over after their early attempts will do them no harm.  The point is to get them to start to handle the toothbrush at an early age, and to get them used to having one in their mouth.  Parents concerned about their child’s oral health may do some of the brushing for them, but it is always best not to make it an unpleasant experience.  Gently done, it can be a bonding experience, especially for moms.  The more comfortable and enjoyable the experience is, the less likely it is that the child will later rebel and begin to associate teeth with unpleasantness.

Should children floss?

Flossing requires manual dexterity that very few children possess.  Again, children do not generally have to worry about gum disease, and decay is more a matter of the frequency of sugar exposure.  Also, children’s teeth tend to be widely spaced and brushing alone does an adequate job of cleaning.  I feel that making flossing an issue is more likely to cause a child to rebel against the whole process of oral hygiene.  Flossing is helpful in preventing decay between teeth too, but that is more easily controlled by limiting sugary foods and drinks (especially between meal juices, Kool Aid, Fruit Rollups and candy).

Is there a difference between baby teeth and adult teeth besides size

Diagram of Adult and Deciduous Teeth
Yes, there IS a difference in both anatomy and physiology.  The first thing to notice in the diagram at the right is the relative difference in size of the various parts that make up the two types of teeth.  The baby tooth (on the left) has a bigger nerve relative to the size of the rest of the tooth than the adult tooth.  That means that decay in any part of a baby tooth has less distance to travel to get to the nerve than in an adult tooth.  When we repair decay in either type of tooth, we always make the cavity preparation larger than the original extent of the decay in order to make the filling mechanically stable, which means that we are more likely to strike the nerve in a baby tooth when restoring it.

This does not mean that it will hurt the child because the child has already been anesthetized.  However, the difference in physiology between baby teeth and adult teeth means that special precautions must be taken if the nerve in a baby tooth is struck in the course of removing decay.

The baby tooth pulpotomy

When the nerve in an adult tooth is exposed during the course of removal of decay, the nerve can often be saved provided that the decay has not caused it to become too inflamed.  This is done simply by stopping the bleeding and covering the exposed nerve with a cement containing calcium hydroxide.  This is known as a pulp cap.  (If the nerve has been too badly affected by the decay, it frequently swells up, and due to the confined space in which it lives, the tissue becomes so tight that blood can no longer flow inside the nerve of the tooth.  When this happens, the first symptom may be severe pain.  In order to relieve the pain, and the abscess that may follow later, the dentist must either remove the tooth or perform a root canal procedure.)

Deciduous pulpotomyIn a baby tooth, pulp caps never work.  The nerve will not survive, eventually causing an abscess.  In order to prevent this problem, the dentist will usually try to save the tooth using a procedure called a pulpotomy.  In this procedure, the top part of the nerve (the part in the pulp chamber) is removed and the remainder of the nerve in the root canals is treated with a cotton pellet soaked in formocresol  which is a medical fixative intended to fix, or “tan” (as leather is tanned) the living nerve that remains in the root canals.

This treatment turns most of the remainder of the nerve into “leather” and it becomes inert and unlikely to hurt or cause a future abscess.  Finally, some temporary filling material is mixed up using formocresol  and this is placed in the pulp chamber and used as a base under a regular filling.

Recently, dentists have been using a solution of  16% ferric sulfate instead of formocresol.  (FS Hemostatic by Premier is a retraction cord solution found in many dental offices which works well.)  This procedure keeps the remainder of the nerve (in the canals) alive, and, in combination with a filling of ZOE (zinc oxide and eugenol), has been shown to relieve a toothache in a deciduous tooth with a live nerve.  Ferric sulfate pulpotomies have been shown to have the same clinical success as formocresol pulpotomies.  Ferric sulfate has the added benefit of stopping bleeding form the pulp.

Note for dental students:  Formocresol  pulpotomies only work if the pulp is alive and bleeding when exposed.  They will not work if the tooth, or any of its canals is already abscessed.  The reason for this is that the purpose of the pulpotomy is to fix, or “tan” the coronal portions of the living tissues in the canals.  This relieves pain, but a secondary purpose is to allow any unfixed portions apical to the canal orifices to remain alive.  The fixed portions of the tissue in the canals remain biologically inert and act a bit like gutta percha, keeping the toxic FC from perking out of the apex into the tissues beyond the tooth and causing a chemical abscess.  Also, formocresol can be applied to the pulp chamber only if all bleeding from the remaining tissue in the canals has been stopped with pressure from a cotton pellet.  If the chamber is closed with a canal still bleeding, the pulpotomy will cause an abscess.  In that case, it would be best to use a solution of ferric sulfate or aluminum chloride (Hemodent) to stop the bleeding first.

Children’s dentistry page 3==>>
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What causes decay?

Oral Hygiene techniques

The three factors that cause dental disease