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Dr. Lou Cooper has dedicated
the last 30 years to servicing the dental health of children, young
adults and the special needs. The office in New York City he
co-founded and practiced in for 27 years became one of the most
renowned pediatric dental groups in the area under his guidance. He
is a graduate of NYU College of Dentistry, receiving a post graduate
degree in Pediatric Dentistry at the Eastman Dental Center,
University of Rochester. Dr. Cooper is on Staff at Lenox Hill
Hospital and is Clinical Instructor in Dentistry, Weill Cornell
Medical College, New York Presbyterian Hospital. Dr. Cooper can be
reached at info@drlou.com or
call 800-656-3000.
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II.
Tooth Development
At birth the crowns of all 20 of the newborn’s “baby” or primary
teeth are almost completely formed. They erupt through the gums
during the first 2 ½ years of life until the full set is complete by
around 3 years of age. Although the front teeth can begin the
eruption process as early as 6 months of age, the timing is subject
to variation.
Even though the baby teeth are “temporary”, they are deserving of
optimum care since they are needed for chewing, speaking, and
appearance. Additionally, they hold the space in the jaw for
permanent teeth which move into place as the primary teeth are shed.
Parents may not be aware that primary teeth can develop cavities,
infection, and pain in the same way as permanent teeth can.
Primary Teeth Infection
Infection from decayed primary teeth can damage the permanent teeth
underneath them. There are twenty primary teeth, some of which may
stay in the mouth until your child is approximately 13 years old.
The
adult teeth will begin to erupt around age 6 with the primary teeth
starting to shed at about the same time. There is a period between
ages 8 and 10 where there are no teeth lost and no new teeth that
come in. This is called the “mixed dentition” phase. Following this
stage, the remaining baby teeth are shed and permanent teeth
continue to erupt until around the age of 13. The Wisdom (Third
Molars) Teeth are the last teeth to emerge at around the age of 18,
completing the full set of 32 permanent teeth.
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III. Dental Decay
 Decay is the process of tooth destruction. This occurs when foods
containing carbohydrates
(sugars
and
starches) such as milk, raisins, cakes bread or candy are consumed
and left on
the
teeth. Bacteria that live in the mouth thrive on these foods,
producing acids as a result. Under the right conditions and over a
period of time, these acids destroy tooth enamel, resulting in tooth
decay.
DENTAL CARIES IS A TRANSMISSIBLE BACTERIAL INFECTION
Dental
caries is a transmissible disease and mutans streptococci is the
principal bacteria responsible for its initiation. This bacteria is
not present at birth but is acquired, usually from the mother.
Acquisition can be from other caregivers, by means of passage of
saliva and shared utensils. The “window of infectivity” is estimated
to be
between 6 and 36 months of age. A high level of bacteria in the
mother’s mouth increases the rate of transmission to the infant.
Children who are infected at this early age can have a higher
lifetime incidence of dental caries.
Early
Childhood Caries (also known as baby bottle tooth decay or nursing
caries) is caused when an infant’s teeth are frequently exposed to
liquids containing sugar e.g. milk (including breast milk), formula,
juices, or other sweetened liquids over extended periods of time.
There is significant risk of tooth decay from using a bottle during
naps, at night, or when nursing occurs continuously. If a baby is
allowed to fall asleep with a bottle, liquids collect around the
teeth thereby subjecting them to the acids being produced by
bacteria. Frequent exposures to these fluids in the bottle or
while nursing increases the acidic attacks thereby placing these
teeth at more risk for severe decay. Encouraging your child to:
-
drink water following the bottle or nursing,
-
feed from a cup,
-
wean from the bottle (by age one),
-
wean from at will breast feeding,
will help
to avoid the tooth destruction caused by Early Childhood Caries.
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IV. Prevention
The following are some ways that can help prevent
tooth decay:
-
Brush twice a day with fluoride toothpaste.
-
Clean between your teeth daily with floss or
interdental cleaner.
-
Eat nutritious and balanced meals and limit snacking
in between meals.
-
Check with your Dentist about use of supplemental
fluoride
-
Have your dentist apply dental sealants (a plastic
protective coating) to the chewing surfaces of the back teeth to
protect them from decay.
-
Visit your dentist regularly.
1) Brushing and flossing
 Make sure
that all surfaces of the teeth are brushed (insides and out), at
least twice a day with a fluoride toothpaste focusing along the gum
line as well as the chewing surfaces of the back teeth. For infants
begin using a “pea size” amount of toothpaste and encourage spitting
it out. The ability to spit occurs by the age of around 3 years of
age, however hold off and chose a toothpaste without fluoride if
your child is unable to do so.
 The
only way to effectively clean in between the teeth is by using
floss. Once it is gently inserted and wiggled down, do not use a
back and forth motion. This can cause damage to the tooth over time,
and injure the soft tissues. Flossing is a technique that your child
will need your help with until they have the manual dexterity to
accomplish it on there own. It is also not uncommon for parents to
help brush their children’s teeth until the ages of 6 and 7 (or
later depending on the child), at which time hopefully brushing
skills can be effectively mastered.
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2) Diet
a) Many
of us forget that diets high in carbohydrates not only consisting of
sugars, but starches as well can place children at extra
risk for tooth decay. Foods with starch include breads and crackers,
and snacks such as pretzels and potato chips.
b)
The more retentive foods (those that stick to the
teeth), pose more potential for harm.
c) Limit
the number of snack times in between meals, preferably saving foods
with sugar or starches for meal times.
d)
Try to provide healthy snacks such as cheese, yogurt,
vegetables, and fruit.
e) Try
sugarless gum as a substitute for snacking, or chew it following a
snack to stimulate the flow of saliva.
3) Fluorides
For children who are
at moderate or high risk of developing cavities (e.g. those with a
history of caries, poor brushing technique, poor diet), additional
fluoride modalities could be beneficial:
a) Over
the counter fluoride rinses such as ACT, or Phosflur used in
conjunction with twice daily brushing in
addition to a fluoride toothpaste.
b) For
children over 6 who are high risk, a
prescription brush-on dentifrice with a high concentration of
fluoride content (e.g.”Prevident”), as a replacement for their
regular dentifrice.
c) Office
application of Topical Fluorides via trays, or Fluoride Varnishes
could enhance protection of the tooth structure and aid in its
repair.
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4)
Sealants
Application of Sealants to protect the chewing
surfaces of the molars can be very effective in protecting those
very retentive, susceptible sites. They provide a barrier from food,
and bacteria accumulating in the crevices of these teeth.
Application is painless and easy.
5)
Sugarless gum
The use of sugarless
gum especially with Xylitol helps to stimulate saliva which in turn
aids in putting minerals back in to tooth structure (remineralization)
aiding in its repair.
6)
Antibacterial
Rinses
At present
the most effective
antibacterial rinse against cariogenic bacteria is chlorhexidine
gluconate, 0.12%. This modality is used for older children and
adults to help reduce the bacteria that most commonly produce
cavities.
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V.
Infant Care
 Encourage your child
to drink from a cup as early as possible. Not sleeping with the
bottle or nursing your child to sleep after the first baby teeth
erupt is critical in preventing Early Childhood Caries. As soon as
the first teeth erupt they should be cleaned with water or a
fluoride free toothpaste until your child is able to spit. A
toothbrush, gauze pad, or washcloth over the finger can be used,
wiping the teeth gently. This should be done at least twice a day
and following feedings, when possible. A small “pea sized” amount of
fluoride toothpaste can be introduced to provide extra benefits when
the “art” of spitting it out is mastered. Be careful that excessive
amounts are not ingested regularly, since the potential exists to
cause damage to the developing permanent teeth. Children do not have
the manual dexterity to clean their teeth effectively, so you must
be an active participant in your child’s oral hygiene.
Keep in mind the
dental caries is an infectious and transmissible disease. The mutans
streptococci (MS) are infectious agents most strongly associated
with dental caries. Some studies have demonstrated that infants
acquire MS from their mothers only after the eruption of primary
teeth.
A high level of
bacteria in the mother’s mouth can increase the rate of transmission
to her infant which in turn places the child’s mouth at greater risk
for developing cavities. Optimizing the oral health of the mother
through the reduction of cavity causing bacteria not only benefits
her, but her child as well. Mothers can translate this newly
reported information into action by:
-
not passing saliva that might find it’s way into her child’s mouth
(through kissing, or cleaning a pacifier with saliva)
-
reducing levels of oral bacteria through good oral hygiene
-
using antimicrobial mouthrinses to reduce the bacterial levels in
their mouths as advised by her Dentist
-
maintaining regular visits to the Dentist
When the first teeth
erupt, it is a good idea to plan for the first dental visit. At
that time the Dentist will examine the child, determine the child’s
risk for dental disease, review feeding and diet practices, instruct
the parent on proper hygiene, and counsel the parent regarding
habits that could be detrimental to the child’s dental development.
If needed, a cleaning will be performed and any preventive
procedures that might be helpful in maintaining good oral health.
According to the American Academy of Pediatrics' Policy Statement on
oral health risk assessment timing and establishment of the Dental
Home “every child should begin to receive oral health
risk assessments by 6 months of age from a
pediatrician or a qualified pediatric health care
professional”. This parallels earlier
recommendations by the American Academy of Pediatric Dentistry, and
the American Dental Association calling for the first oral
examination by one year of age.
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VI. Pacifier
and Finger Habits
 Pacifier
and finger habits are normal for babies and young children. It
provides security
for some children and is a way for babies to make contact with
and learn about the world. In fact, babies begin to suck on their
fingers or thumbs even before they are born. These habits may also
help induce sleep which explains why children often use pacifiers or
fingers in the evenings or at other times when they are tired.
Prolonged
habits can result in problems relating to the proper growth of the
mouth and alignment of the teeth. The frequency and intensity of the
sucking action are factors which determine whether or not dental
problems will result. Should finger habits continue past the age of
four, discuss them with the dentist to see if there are ways to help
your child discontinue it through conditioning, reinforcement, and
other motivational methods. Sometimes mouth appliances are helpful
with children who are interested in stopping but cannot on their
own. Pacifiers are easier habits to break since parents have more
control over their use. Maturity is often the best cure, however as
we know the age that this occurs varies from child to child. So, we
must be patient, give support and hopefully peer pressure will be
the motivating factor that will bring us success in breaking these
habits. Some other tips that might be helpful:
-
Offer
praise for not sucking instead of scolding for
sucking
-
Focus
on correcting the cause any anxiety that might be a stimulus for
these habits
-
Reward
your child when they avoid the habits during difficult times
-
Reminders could be helpful e.g. bandaging the thumb, placing a
sock over your child’s hand at night
-
Expect
to work hard at helping your child with the habit, being
sympathetic, supportive, yet persistent in your efforts
-
Use a
chart to have your child participate in so they can gauge their
successes, reinforcing with gifts when established goals are
achieved
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If all
efforts fail, do not be discouraged most problems can be treated by
routine orthodontics.
VII. Orthodontics
Orthodontics seeks to
correct teeth and jaws that are not positioned normally. Teeth that
are not straight or fit together properly are much more difficult to
keep clean, are more prone to periodontal disease, and can cause
issues in the muscles of the jaws and its joints. The benefits of
orthodontics not only can produce a healthier mouth, but of course
also result in a much more pleasing appearance.
By the age of seven
most children have a combination of both baby and adult teeth. Even
at that early an age children can benefit from “interceptive
orthodontics” to limit or correct a bite that may not be developing
optimally. The objective is to reduce the severity of developing
problem and to try to eliminate its cause. Straight teeth are not
the only criteria by which the bite is evaluated for early
treatment. The need for early orthodontic intervention is sometimes
indicated by the following:
-
Difficulty in chewing or biting
-
Aggressive finger habits
-
Severe crowding or blocked out teeth
-
Teeth not erupting in the right direction
-
Jaws that shift
-
Biting of cheeks
-
Teeth that do not meet properly
-
Jaws that are not growing harmoniously
-
Lower
risk of trauma to protruded upper incisors
-
Improve aesthetics and self-esteem
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Although a problem is
“intercepted it does not mean that additional orthodontics may not
be necessary in a second phase of treatment.
 It is not uncommon
for an appliance called a “space maintainer” to be made when a baby
tooth is lost prematurely. This holds needed space for the permanent
teeth that will be coming in later, and prevent collapse of other
teeth into the space.
There are times when
it is necessary to remove baby teeth to allow severely crowded
permanent teeth to come in that might otherwise might not (impact),
or improve their position. The upper permanent canines are teeth
that have a tendency to find themselves in positions necessitating
removal of the baby canine.
After all permanent
teeth come in, the extraction of certain permanent teeth may be
necessary to correct crowding. If there is insufficient space
available to accommodate all the teeth, then sometimes there is no
other choice. The sequential removal of both baby teeth and
permanent teeth in order to alleviate a severely crowded is called
“serial extraction”. It allows teeth to move on their own into much
more desirable positions, and is usually followed by comprehensive
orthodontic treatment.
There are various
appliances that are used to accomplish specific goals:
Headgear: Applies
pressure to the upper teeth and jaw to guide the direction of upper
jaw growth and tooth eruption.
Palatal Expander:
This appliance is fixed to the upper back teeth, markedly expanding
the width of the upper jaw. In some patients it may prevent the need
for extraction of permanent teeth.
Functional
Appliances: Removable and fixed in the mouth, help to guide teeth
and jaws into a more normal bite
Habit appliances: Are
usually attached by bands to the molars and used to control thumb
sucking or tongue thrusting.
Braces: Are the most
common appliances. They use bands, wires, and brackets most often
bonded to the teeth, gradually moving them into a proper position.
Retainers: These can
be fixed or removable, and are worn to prevent shifting of teeth
into their previous positions.
Aligners: These are
alternatives to traditional braces being used in selective
individuals to move teeth without metal brackets or wires. They are
clear, virtually unnoticeable and are removed for eating and
brushing.
Extra time and effort
is necessary to keep orthodontics appliances clean and the teeth
with its gums healthy. When plaque and debris collect around braces
they can produce unsightly white spots that can lead to decay.
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Some additional ways to help keep
teeth and gums healthy that have appliances is by:
1.
using specialized
brush tips get in between the braces and under the wires
2.
using floss threaders under the wires
3.
using oral irrigators to dislodge food and debris
from around the teeth
4.
using over the counter fluoride mouthrinses (Phosflur) and
prescription toothpastes (Prevident) to give the teeth extra
protection
5. brushing
after meals and staying away from harmful foods that are retentive
6. Visiting
the dentist more frequently for cleanings, concentrated fluoride
applications (Fluoride Varnish), and hygiene reinforcement
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VIII.
Emergencies
It is not uncommon
for a child to suffer some kind of dental injury while growing up,
and often they appear more serious than they really are.
Nevertheless, it is important that you have your dentist and
emergency room phone numbers readily available when you need them.
Many injuries are as result of participation in a sport (which mouth
guards would help to prevent) or falls, some requiring the care of a
dentist. Injuries involving the head, neck or face may require a
visit to the emergency room or the Pediatrician. Some of the more
common emergencies are listed below with advice as to how to manage
them:
1. Cuts:
Apply pressure with clean gauze or cloth. Place ice in contact with
the area of the wound to control bleeding and swelling. Call your
child’s dentist. If the bleeding cannot be controlled, take your
child to a hospital emergency room immediately.
2.
Toothache: This is often attributed to untreated tooth decay. Have
your child carefully remove food from the area with a
brush or floss. Do not chew in the area if possible and avoid
extremes of temperature. If swelling is present apply cold
compresses, and do not use heat or aspirin placed on the gum
of
the aching tooth. Provide Tylenol or Ibuprofen for pain and call
your child’s dentist as soon as possible.
 3. Bumped
Tooth: Check for any soft tissue damage, and apply cold compresses
to the area. Do not chew on the area, and note if tooth is in the
same position or not. Call your child’s dentist. If teeth that have
been bumped turn color, it may very well be because the nerve has
been affected. Should this occur contact your child’s dentist.
4. Cracked
Tooth: Rinse the mouth with warm water to remove dirt
and debris from
the area.
Apply
cold compresses to the lip and face in the area of the injury to
control swelling. If you can find the tooth fragments save them, and
see your child’s dentist immediately taking the fragments with you.
5. Intruded
Baby Tooth: If your child suffered trauma, and there appears to be
teeth missing that cannot be found, it is possible that the tooth
(or teeth) was pushed in to the gums. Blood and swelling in the area
will make it even more difficult for the tooth to be visualized.
Control the bleeding and see your dentist immediately to discuss
treatment options.
6. Knocked
out Baby Tooth: Find the tooth, control bleeding, and see
your child’s Dentist. Do not reimplant the tooth, but do bring
it with you.
7. Knocked
out Permanent Tooth:
a. Find
the tooth. Hold the tooth by the crown (the white part), not by the
root (the yellow part).
b. Replant
immediately, if possible.
c. If
contaminated, rinse shortly with cold tap water and put the tooth
back in its place. This can be done by the child or an adult.
d. Hold
the tooth in place. Bite on a handkerchief to hold it in position
and go to the dentist immediately.
e.
If you can not put the tooth back in, place it in a cup of milk or
saline. When milk or saline are not available, place the tooth
in the child's mouth (between the cheeks and gums)
f.
Seek immediate treatment. Time is of essence.
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Children between 7
and 10 years of age are more exposed to suffer avulsion (a tooth
being knocked out of the mouth) due to the elasticity of the bone at
this age.
8. Loose
Braces and Wires: See your child’s dentist as soon as possible. In
the interim, you can make your child comfortable by covering the end
of the wire or bracket with cotton, gauze, wax, or chewing gum. If
any part of the appliance is loose, try to gently remove it from
mouth without force and place it in a container to bring to the
dentist. Should the appliance be embedded in the gum, tongue, or
cheek, see your child’s dentist immediately.
 9. Self
–Inflicted Injury: Children can very easily injure their cheek,
tongue, lips that have been anesthetized following dental work. They
should be carefully observed until the numbness is gone, and
frequently reminded to not bite these structures. If damage does
occur call your child’s dentist immediately.
(3 Photos shown in #9 & #10 Courtesy of
Logical Images, Inc.
Published online at www.visualdxhealth.com)
10.
Canker Sore and
Cold Sores: Canker sores, or Apthous ulcers are very common and not
contagious. They are white ulcerations with red borders that are
very painful. They always occur on the inside of the mouth which
distinguishes them sometimes from Cold Sores. Exact cause is
unknown, but it is thought they may be associated with an immune
system reaction. Fatigue, stress, or allergies may be precipitating
factors. They usually heal on their own within one to two weeks, but
children should avoid irritating, caustic foods to limit the
discomfort. Palliative treatment in the form of over the counter
ointments e.g. Orabase and Benzocaine, or prescription medications
can be provided by your dentist.
Herpetic stomatitis is a contagious viral illness (Herpes Simplex
Virus) and is seen mainly in young children. This condition is
probably a child's first exposure to the herpes virus, and it can
result in a systemic illness with high fever, blisters, ulcers in
the mouth, and inflammation of the gums.
Sometimes the blisters are very
painful, often forming in groups inside the mou th, around
the lips, and sometimes the face. These are contagious, and are
often fluid filled. Once a child has a
primary infection, it stays in the body and does have the potential
to produce recurrent
attacks. They usually heal on their own within one to two weeks.
Treatment is often palliative with over the counter creams and
ointments,
although severe cases are treated with antiviral drugs.
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11.Wisdom
Teeth:
The “Wisdom Teeth” are the third molars and are usually the last
teeth to develop between the middle teenage years and early
twenties. Often times these teeth become a source of discomfort
especially when they become infected, erupt malpositioned or are
impacting. Many of the problems associated with these teeth are
associated with lack of space. Should that be the case it is wise to
have these teeth to be removed. Even if the wisdom teeth are not
symptomatic, the lack space could be sufficient reason for having
them removed in your teens or early twenties. At this age one heals
faster, with generally fewer post operative complications.
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lX.
Children with Special Needs
Parents should not be
deterred from seeking dental care for their special needs child.
Some of these children are very susceptible to decay, gum disease
and oral trauma. Others require medications and have diets that are
detrimental to good oral health. This is all complicated by the
difficulty in managing behaviors at home that will enable
appropriate oral hygiene measures. The Pediatric Dentist is
specially trained to best deal with the needs of this population.
Those
with significant medical, physical, or mental disabilities often
present unique challenges to dentists. The specialty training a
Pediatric Dentist has provides those patients with significant
medical, physical, or mental disabilities the best care possible.
Parents
should take advantage of this expertise and try to maximize on the
services available to give their children the opportunity to
optimize their dental health.
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