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Pediatric Dental Health

December 1, 2002

BABY TEETH - THE BASICS

For an infant, the mouth is a very sensitive area which he uses to meet his mother, to satisfy his constant hunger,
to comfort himself, and to explore objects in the new world around him.

WHEN DO BABY TEETH COME IN?
A child's primary teeth, sometimes called "baby teeth," are as important are the permanent adult teeth.
Primary teeth often begin to appear when infants are 6 months old, and help them chew and speak.
The first baby tooth to erupt is the lower primary central incisor.

TEETHING:
The eruption of baby teeth begins when other changes in an infant's immune system, growth, and development are also occurring. The eruption of the primary teeth usually begins around 6 months of age. This is, coincidentally, when infants have lost most of their maternally-derived antibody protection. By the age of 6 months, the number of maternal antibodies has decreased to a very low level, predisposing an infant to a variety of infections.

Drooling in infants reaches its maximum level just before tooth eruption. This is because in early infancy, the ability to swallow all of the saliva is not yet well-developed. Putting objects in the mouth, and biting them, also first occurs at the time of teething. This newly-acquired ability to "mouth" objects is simply part of the normal neurological development of a child.

What can be done about the pain associated with teething?

Have two clean teething rings, which have been chilled, ready for baby chew on.

Give children's Tylenol elixer, as needed, to alleviate pain and inflammation.

Note that using benzocaine ointment on baby's gums may not be a good idea because:
Benzocaine ointment may sensitize your baby to future benzocaine-related allergic reactions.
Benzocaine ointment may cause numbing of the throat, and your baby may choke if too much is used.

BRUSHING BABY TEETH:
Oral hygiene techniques may be modified depending on a child's age. For small infants, the gums need to be cleaned once or twice a day with a piece of clean gauze. This will help to establish a healthy oral environment for the baby teeth. Infants should be introduced to the toothbrush around the age of one.

A baby tooth cleanser should be used up to the age of 3.
After the age of 3, a pea-sized drop of children's toothpaste can be applied to the toddler's brush.

Brushing baby teeth can be quite a challenge for new parents. Some infants and toddlers may refuse to let parents brush their teeth. What can parents do? Parents can experiment with various rewards for good behavior during brushing. The initial tooth brushing attempts need to last only 5 seconds or so - and some little reward should be provided immediately thereafter. The time spent brushing the teeth can be gradually increased later on. Using this "rewards technique," parents can follow the first successful attempt at tooth brushing with letting their baby "play with a favorite toy" or "play a favorite game with mom or dad."

WHAT IS EARLY CHILDHOOD CARIES?
Early childhood caries (ECC) is a multifactorial disease which affects children worldwide. It is an aggressive oral disease which can occur in children up to the age of three. It initially affects the upper front teeth, and eventually spreads to the primary first molars. This new term, ECC, encompasses baby bottle tooth decay, nursing caries, rampant caries, sipper cup caries, and caries related to consumption of soft drinks.

An infant's mouth contains millions of bacteria, including the infectious mutans streptococci. These bacteria are the initiators of the caries disease process. When a parent puts the baby's feeding spoon into his or her mouth, the mutans streptococci bacteria from the parent's mouth will be transferred back to the baby's mouth and infect the baby's teeth. This process can take place as early as eleven months of age. The danger of infecting the infant's teeth is increased when the mother already has the caries disease herself.

The factors affecting the occurrence and severity of ECC include:

Diet and nutrition.

Oral hygiene.

Fluoridation.

Preventive dental measures.

Transmission of cariogenic microbes from mother to child.

A child's genetic susceptibility to dental disease.

Salivary flow and its pH buffering capacity.

Mucosal immunity.

Lifestyle.

A history of previous dental caries.

DIET AND YOUR BABY’S TEETH:

From birth to four months of age:
The American Academy of Pediatrics recommends that breast milk be the only nutrient fed to infants until 4 to 6 months of age.
For mothers who do not breastfeed, infant formula can be used. Formula-fed babies may need to eat 6 to 8 times per day for a total of 16 – 35 ounces per day.

Four to six months of age:
At this age, the baby should be consuming 28 to 45 ounces of formula per day.

Six to eight months of age:
Solid foods can be introduced into the infant’s diet. Mother should wait until the baby has good control of the head an neck. At that point, start with a thin consistency mixture of baby rice cereal. Later, try offering strained fruits and vegetables. Infants should not be allowed to use a sippy cup for prolonged periods of time. Drinking fruit juice for a prolonged period of time will likely lead to the development of dental caries.

Eight to twelve months of age:
By the age of one, most children should be “off the bottle.” Offer the baby strained meats at this age.
Remember, infants should not be put to sleep with a bottle containing any liquid other than water.

One year of age:
Whole milk or 4% milk may now replace breast milk or formula. Children under the age of 2 should not be given low-fat (2% or skim) milk.
Parents should encourage their infants to drink from a cup as they approach their first birthday.

Toddlers and older children:
Do not give food that may cause your toddler to choke – such as nuts, popcorn, raisins, hot dogs, grapes, or berries.
Infants should not be put to bed with a bottle containing juice or milk. Only water should be in the bottle at bedtime!

One to two years of age:
Toddlers should be discouraged from carrying a sippy cup. Toddlers who drink more than 12 fluid ounces of juice per day may develop dental caries and “toddlers’ diarrhea.”
Toddlers should be introduced to healthy food and snacks.
Yogurt and cheese are good calcium alternatives for children who cannot tolerated milk.

Children are the single largest group of juice consumers. By the age of one, almost 90% of infants in the U.S. are drinking fruit juice. One percent of infants consume more than 21 ounces of juice per day!

Fruit juice is not a substitute for natural fruit, and it has fewer nutrients. Water and carbohydrates are the main ingredients in juice. The major carbohydrate components of juice are: sucrose, glucose, fructose, and sorbitol. Fruit juice also lacks the fiber in whole fruit.
Malnutrition, short stature, and dental caries in children have been associated with excessive juice consumption. Excessive consumption of juice by infants can also cause diarrhea due to poor absorption of the carbohydrates in juice. Abdominal pain is also common in heavy juice drinkers.
The American Academy of Pediatric Dentistry and the American Academy of Pediatrics both recommend that juice be offered to infants in a cup – not in a bottle or sippy cup. Infants should not be put to bed with a juice bottle or sippy cup.
It is recommended that fuit juice be consumed during meal time. Juice should not be used to pacify a child, and should not be sipped all day.

Two years of age and up:
Aged cheese contains calcium lactate and fatty acids which help fight cavities. The calcium and phosphates in aged cheese are slow-release components which are needed for tooth remineralization. In addition, the physical form of cheese promotes salivary flow – which increases food clearance and decreases the acidic environment surrounding the teeth.

HOW CAN PARENTS IDENTIFY DENTAL CARIES?

1. The first sign of dental caries is a white spot "lesion" on the enamel surface of the front teeth. These are white, chalky areas, close to the gum line. These decalcifications are caused by bacterial acid, and directly precede irreversible loss of tooth structure (a cavity).

2. By "lifting-the-lip" parents will be able to see this early indicator of caries disease.

3. Parents should get these areas examined by a dentist as soon as possible, so that treatment can be initiated, if necessary. The white spot lesions can be "reversed" (remineralized) by the application of fluoride - if the problem is recognized early enough.

4. Active cavities usually have a golden-brown color.

HOW CAN PARENTS PREVENT DENTAL CARIES?

Parents should not put children to sleep with a bottle containing any liquid other than water. Parents should encourage their infants to begin drinking from a cup around their first birthday.

Parents should help brush their children's teeth every day, after every meal.

Parents should not let their children drink fruit juice or sweetened drinks from a bottle or "tippy" cup, since this prolongs the exposure of teeth to harmful sugar.

Parents should provide healthy, balanced meals for children. They should limit the amount of sugar-laden foods and snacks in their diet. Plenty of healthy snacks should be available for children. Cheese products actually fight dental caries.

Parents can help make children's teeth more decay-resistant by using an ADA-approved children's toothpaste. Place only a pea-sized drop of toothpaste on the toothbrush. Until a child is 3 years old, parents should only use baby tooth cleanser - to avoid causing fluorosis discoloration of the adult teeth.

Children taking oral medications should have their teeth cleansed after each dose of medication. Nearly 100% of children's medications contain sucrose, which can increase the risk of developing dental caries.

Children should have their first oral/dental health evaluation by the age of 12 months, or within 6 months of the eruption of the first tooth.

Parents should consider providing children with xylitol-containing chewing gum, which can help prevent dental caries.

FIRST DENTAL VISIT:
"An ounce of prevention is worth a pound of cure." How well this proverb applies to children's dental health! The American Dental Association, the American Academy of General Dentistry, and the American Academy of Pediatric Dentistry all recommend that your child's first oral health visit take place at 12 months of age, or shortly after the eruption of the first baby teeth. This is the ideal time for a dentist to evaluate your child's oral and dental health, as well as to diagnose any problems which may exist.

THUMBSUCKING

The mouth provides a baby's first contact with the external world, and sucking is an infant's first coordinated muscular activity. Babies even suck their thumb before they are born. The survival of a newborn baby depends on instinctive nutritive sucking, which allows for essential nourishment. Infants also engage in nonnutritive sucking of their fingers and thumbs, which provides them with a sense of well-being, comfort, and security.

Thumb sucking, however, can also have negative influences on both dental development and speech. Prolonged thumb sucking can deform a child's upper dental arch, cause a crossbite, protrude teeth, and create an open bite. The extent of these negative consequences are affected by the duration of the habit, the daily frequency of the habit, and the manner in which the thumb is placed into the mouth.

Children tend to suck their thumb when they are tired, bored, under stress, or in need of comfort. Taking away the soothing effects of a thumb habit may result in poor conduct by the child. Preventing a thumb habit, against the wishes of a child, may result in learning problems, bed wetting, sleep disorders, initiation of a new habit, or persistence of the old habit.

After the age of four, correction of a thumb habit may involve using psychological and/or physical preventive measures. Evaluation by a psychologist, pediatrician, and pediatric dentist may be necessary for the eventual resolution of the problem. The ultimate goal, however, should be to correct the cause of the habit, rather than the habit itself.

An article in Contemporary Pediatrics explains some of the hazards associated with prolonged thumb sucking after the age of 4. It describes some of the treatment options for this common problem.

Van Norman, RA: Why we can't afford to ignore prolonged digit sucking. Contemporary Pediatrics, June 2001.