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912 Grand Ave | San Rafael, CA 94901 | Ph: 415-459-1444

Dr. Aparna Aghi

• Harvard and UCSF Trained
• Diplomate of the American Board of Pediatric Dentistry
• Asst. Professor and Clinic Director, UCSF Pediatric Dental Dept.

Dr. Martin Sinai Rayman

• Diplomate of the American Board of Pediatric Dentistry
• 35+ years experience practicing in Marin
• Visiting Professor at educational institutes throughout CA



Dental Topics


Girl - Pediatric Dentist Dr. Aparna Aghi and Dr. Martin Rayman

Click on a topic of interest for more information.

GENERAL TOPICS:

Dental Insurance Explanation
What Is A Pediatric Dentist?
Why Are The Primary Teeth So Important?
Dental Radiographs (X-Rays)
Eruption Of Your Child's Teeth
Dental Emergencies
Sedation For The Anxious Child
Fluoride
Why Are There Stains On My Child's Teeth?
Gastroesophageal Reflux - Effect On Teeth
Hypocalcified Teeth
What Is Pulp Therapy?
What Is The Best Toothpaste For My Child?
Why Does My Child Grind His/Her Teeth?
Thumb Sucking
What Is The Best Time For Orthodontic Treatment?

EARLY INFANT ORAL CARE:

Parental Guidelines For Preparing Your Child For Their First Dental Visit
When Will My Baby Start Getting Teeth?
If Teeth Could Talk - Is Teething Painful
Baby Bottle Tooth Decay (Early Childhood Caries)
Sippy Cups

PREVENTION:

San Rafael Pediatric Dentist
Good Diet = Healthy Teeth
How Do I Prevent Cavities?
Plaque
Chlorhexidine Gluconate
Xylitol Frequently Asked Questions
Xylitol RX
Resin Fillings Used To Prevent Cavities
Alternative Restorative Technique For Early Childhood Caries
Demineralization Vs Remineralization
Mouth Guards

ADOLESCENT DENTISTRY:

Tongue Piercing - Is It Really Cool?
Tobacco - Bad News In Any Form

POST OPERATIVE CARE INSTRUCTIONS:

RECOMMENDED LINKS:

For more information on oral health care needs, please visit the website for  the American Academy of Pediatric Dentistry, My Childrens Teeth and http://www.aapd.org/headstart/staffdvd.asp

If you are still searching for information not included in our web site you might try the following links: 

MyChildrensTeeth.org
American Academy of Pediatric Dentistry
California Society of Pediatric Dentistry
My Pyramid - Nutrition
Dental Cavities Can Be Contagious
2Min2X - Dr. Rayman recommends that children under 2 need a small smear of fluoride toothpaste

A great book for your child to read about visiting a dentist:
Dr. De Soto - by Wm. Steig - available in English & Spanish and on video


General Topics

Dental Insurance Explanation

How Insurance Works

Having dental coverage can make getting the dental care your child needs easier. It’s important to understand that most dental insurance plans do not cover all dental procedures. When ultimately deciding on your child’s dental treatment, dental benefits shouldn’t be the only consideration.

You should be informed and know what your dental plan covers and what it doesn’t. It is also important to know what type of policy you have, HMO/DMO or PPO. An HMO/DMO requires you see an assigned dentist within their network. Policies that are PPO allow you to see the dentist of your choice.

Ultimately, your child’s treatment should be determined by you and your child’s dentist--not by your level of dental coverage.

How dental benefit plans work

Many dental plans involve a contract that is between your employer and dental plan provider. You can also buy individual dental plans on your own through Health Insurance Marketplaces.

Your dental coverage is NOT determined by your child’s dentist.

Your child’s dentist’s primary goal is to assist you and your child in maintaining good dental health, but not every procedure your child’s dentist recommends will be covered by your insurance. To avoid any surprises on your bill, it’s important to understand what and how much your dental plan will pay.

Your employer and the plan provider agree on the dollar amount your plan pays and what procedures are covered. Your child’s dentist is not involved in deciding your level of coverage.

Dental Plans Share Treatment Costs with you

There are certain cost-control measures that dental plans use to determine how they share treatment costs with you.

Here’s some key terms that are used to describe their measures:

A deductible is the amount of money that you must pay before your benefit plan will pay for any service. It can take more than one service or visit to meet your deductible. Most plans don’t require a deductible for preventive services like cleanings and exams for diagnostic services.

In the majority of cases, after you meet your deductible you will be expected to pay a percentage of the allowed amount of a covered dental service. This is called your co-pay/coinsurance.

For example: your coverage may pay 80% and you must pay the remaining 20% owed to your child’s dentist. If your bill totaled $100, then your plan pays $80 and you would pay the remaining $20.

This is the maximum dollar amount a dental insurance plan will pay during a year. Your employer decides the maximum levels of payment in its contract with the dental provider.

You would pay for anything over that set dollar amount.

For example:

Your child’s dental expense: $3,000

Your annual maximum: $2,500

You owe: $500

These terms apply to patient’s covered by more than one dental plan (dual insurance coverage). The benefit payments from all plans should NOT add up to more than the total charges. Even though you may have two or more dental benefit plans, there is no guarantee that all of the plans will pay for your child’s services. Sometimes, none of the plans will pay for the services your child needs. Each dental plan handles COB in its own way. Please check your plans details.

Dental plans may limit the number of times it will pay for your child’s treatment. But, your child may need a treatment more often to maintain good oral health. Make treatment decisions based on what is best for your child’s health, not just what is covered by your plan.  

For example: Your plan may pay for teeth cleaning only twice in a calendar year, but your child’s needs cleaning 3 times a year, so you would pay out of pocket for the extra cleaning.

Dental plans may also have an age limit as to what age they will or won’t cover a service. In the case of dental sealants, some plans state the age limit may be up to the age of 13 but not including 13. If you still wanted to proceed with sealants at the age of 13 and higher, the cost would be out of pocket.

Many dental plans state that only procedures that are medically or dentally necessary will be covered. If the claim is denied, it does not mean that the services were not necessary. Treatment decisions should be made by you and your dentist.

If your plans rejects your child’s claim because a service was “not dentally necessary”, you can appeal. Work with your benefits manager and the plan’s customer service department to appeal the decision in writing.

Downgrading- when a dental plan changes the procedure code to a less complex or lower cost procedure than what was reported completed by your child’s dental office.

Make Your Child’s Dental Health the Top Priority

Although you may be tempted to make decisions about your child’s dental care based on what your dental plan will pay, remember that your child’s health is the most important thing. Talk to your child’s dentist to make sure they are getting the treatment that will get or keep their mouth healthy.

What Is A Pediatric Dentist?

The pediatric dentist has an extra two to three years of specialized training after dental school, and is dedicated to the oral health of children from infancy through the teenage years. The very young, pre-teens, and teenagers all need different approaches in dealing with their behavior, guiding their dental growth and development, and helping them avoid future dental problems. The pediatric dentist is best qualified to meet these needs.

Why Are The Primary Teeth Important?

It is very important to maintain the health of the primary teeth. Neglected cavities can and frequently do lead to problems which affect developing permanent teeth. Primary teeth, or baby teeth, are important for (1) proper chewing and eating, (2) providing space for the permanent teeth and guiding them into the correct position, and (3) permitting normal development of the jaw bones and muscles. Primary teeth also affect the development of speech and add to an attractive appearance. While the front 4 teeth last until 6-7 years of age, the back teeth (cuspids and molars) aren’t replaced until age 10-13.

Dental Radiographs (X-Ray Films)

Radiographs (X-Ray Films) are a vital and necessary part of your child’s dental diagnostic process. Without them, certain dental conditions can and will be missed.

Radiographs detect much more than cavities. For example, radiographs may be needed to survey erupting teeth, diagnose bone diseases, evaluate the results of an injury, or plan orthodontic treatment. Radiographs allow dentists to diagnose and treat health conditions that cannot be detected during a clinical examination. If dental problems are found and treated early, dental care is more comfortable for your child and more affordable for you.

In our office we recommend  the first radiographs (4) at about 4 1/2 years of age, depending on what we discover in our initial examination of your child.  Follow-up radiographs are recommended at 6-month to 2-year intervals depending on decay or growth issues that we are monitoring, presence of fluoride in the child's water supply, and home brushing and flossing.  The American Academy of Pediatric Dentistry recommends radiographs and examinations every six months for children with a high risk of tooth decay.

Pediatric dentists are particularly careful to minimize the exposure of their patients to radiation. With contemporary safeguards, the amount of radiation received in a dental X-ray examination is extremely small. The risk is negligible. In fact, the dental radiographs represent a far smaller risk than an undetected and untreated dental problem. Lead body aprons and shields will protect your child. Today’s equipment filters out unnecessary x-rays and restricts the x-ray beam to the area of interest. High-speed film and proper shielding assure that your child receives a minimal amount of radiation exposure.  Our panoramic machine is digital, which decreases, even more, the amount of exposure to radiation.

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Eruption Of Your Child’s Teeth

Children’s teeth begin forming before birth. As early as 4 months, the first primary (or baby) teeth to erupt through the gums are the lower central incisors, followed closely by the upper central incisors. Although all 20 primary teeth usually appear by age 3, the pace and order of their eruption varies.

Permanent teeth begin appearing around age 6, starting with the first molars and lower central incisors. This process continues until approximately age 21. Permanent teeth are darker (more yellow) in color than primary teeth. They are denser and made to last a lifetime

Adults have 28 permanent teeth, or up to 32 including the third molars (or wisdom teeth).

See The Mystery of Teething form more information.

TOOTH DEVELOPMENT


The following are recommended books concerning losing teeth:

Loose Tooth Luke
by Patsy Jensen

Arthur's Loose Tooth
by Lilian Hoban
 

My Tooth is About to Fall Out
by Grace Maccarone

The Lost Tooth Club
by Arden Johnson

 

The Missing Tooth
by Joanna Cole

 

Arthur's Tooth
by Marc Brown

Dental Emergencies

Toothache: Clean the area of the affected tooth thoroughly. Rinse the mouth vigorously with warm water or use dental floss to dislodge impacted food or debris. If the pain still exists, contact your child's dentist.  DO NOT place aspirin on the gum or on the aching tooth. If the face is swollen apply cold compresses and contact your dentist immediately.

Cut or Bitten Tongue, Lip or Cheek: Apply ice to bruised areas. If there is bleeding apply firm but gentle pressure with a gauze or cloth. If bleeding does not stop after 15 minutes or it cannot be controlled by simple pressure, take the child to hospital emergency room.

Knocked Out Permanent Tooth: Find the tooth. Handle the tooth by the crown, not the root portion. You may rinse the tooth but DO NOT clean or handle the tooth unnecessarily. Inspect the tooth for fractures. If it is sound, try to reinsert it in the socket. Have the patient hold the tooth in place by biting on a gauze. If you cannot reinsert the tooth, transport the tooth in a cup containing the patient’s saliva or milk. If the patient is old enough, the tooth may also be carried in the patient’s mouth. The patient must see a dentist IMMEDIATELY!  Time is a critical factor in saving the tooth.

Tooth Hit and Still in Mouth:  If the tooth is fractured (broken), call and go to dental office immediately.  If found, save the piece that's broken off, keep wet and bring to the office.  If the tooth is not fractured (broken), call and go to dental office immediately. (The root of the tooth or surrounding bone may be broken).

Top Tips for Preventing Mouth Injuries

click here to read more

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Sedation For The Anxious Child ~ Nitrous Oxide/Oxygen Analgesia

It is important that your child remains calm and still during dental treatment to prevent injury to your child and dental staff and to receive a high quality of professional dental care. For the child who is afraid, uncooperative, too young to understand dental treatment or requires very long, complicated, treatment visits, nitrous oxide/oxygen for analgesia may be beneficial in helping the child relax.

The following information will help parents understand sedation with the use of a combination of nitrous oxide and oxygen gases for safe analgesia.

Please feel comfortable in discussing with us any other questions you may have about the procedures.

Fluoride

Fluoride is an element, which has been shown to be beneficial to teeth. However, too little or too much fluoride can be detrimental to the teeth. Little or no fluoride will not strengthen the teeth to help them resist cavities. Excessive fluoride ingestion by preschool-aged children can lead to dental fluorosis, which is chalky white to yellow-brown discoloration of the permanent teeth. Many children often get more fluoride than their parents realize. Being aware of a child’s potential sources of fluoride can help parents prevent the possibility of dental fluorosis.

Some of these sources are:

Two-year olds and three-year olds may not be able to expectorate (spit out) fluoride-containing toothpaste when brushing. As a result, these youngsters may ingest an excessive amount of fluoride during tooth brushing. Toothpaste ingestion during this critical period of permanent tooth development is the greatest risk factor in the development of fluorosis.

Excessive and inappropriate intake of fluoride supplements may also contribute to fluorosis. Fluoride drops and tablets, as well as fluoride fortified vitamins should not be given to infants younger than six months of age. After that time, fluoride supplements should only be given to children after all of the sources of ingested fluoride have been accounted for and upon the recommendation of your pediatrician or pediatric dentist.

Certain foods contain high levels of fluoride, especially powdered concentrate infant's formula, soy-based infant's formula, infant's dry cereals, creamed spinach, and infant's chicken products. Please read the label or contact the manufacturer. Some beverages also contain high levels of fluoride, especially decaffeinated teas, white grape juices, and juice drinks manufactured in fluoridated cities. Another source of fluoride can be found in soft drinks at fast food restaurants, when blending the syrup and carbonation with the city water supply.

Fluoride in the water supply decreases by 30% the chance of your child getting cavities.  Fluoride is safe.  If it is not in your water supply (Marin Municipal Water District is fluoridated; North Bay Water District is not), our office will be able to prescribe it.  The dosage changes at 3 and again at 6 and should be taken daily until 16 years of age.  If you are in the MMWD and have a water filtration system or use a lot of bottled water, your child may not be receiving an adequate amount of fluoride and will be more prone to getting cavities!  Bottled water is available with fluoride.

Parents can take the following steps to decrease the risk of fluorosis in their children’s teeth:

Fast Facts About Fluoride

click here to read more
Community Water Fluoridation: Questions and Answers

 

Why Are There Stains On My Child's Teeth?

Stains can be just on the surface of the tooth (extrinsic) or incorporated into the developing tooth (intrinsic). The latter is more rare. Tetracycline antibiotics will stain teeth that are forming at the time of the drug's use. As a result, tetracyclines are no longer given to pregnant women or children under twelve (except in life-threatening cases). The forming teeth may be stained gray to yellow to orange. Some stains can be bleached out; others need to be covered by bonded plastic resins.

More common are stains on the surfaces of the teeth (extrinsic). These accumulate after eruption of a tooth into the mouth. Newly erupted primary teeth may have a yellow membrane on them that will wear of in a few days. Newly erupted permanent teeth appear more yellow than their milky-white primary neighbors. This is their normal, permanent color. The permanent teeth are darker because they are denser so that they can last a lifetime.

White color is not always good. Chalky white spots on permanent teeth can be the result of trauma to a primary tooth while the permanent tooth was developing in the jaw. Or, chalky white lines at the gum line or around orthodontic braces can be a warning sign. Decay starts by removing minerals, especially calcium from the outer surface of the tooth. This softens and allows the acid from the bacteria in plaque to work more quickly. If oral hygiene (brushing and flossing) is started at this point, using a concentrated fluoride paste, and the teeth are kept meticulously clean, these areas can harden again by remineralizing. But, the chalky white lines will remain. If the white turns to brown, the enamel has been broken by the acid attack and the tooth may now need a filling.

If one or two teeth are dark, gray, pink or yellow, this may be the result of that tooth having been hit accidentally. Your child should be seen soon thereafter for an X-ray picture of the tooth and a discussion about possible things that may happen to that tooth.

The rest of the stains mentioned below are all easily removed by a simple polishing done in the dental office with a rotating rubber cup and pumice.

  1. Green or orange stain---usually on the front teeth at the gum line. It is caused by color-producing (chromogenic) bacteria. Colonies of these orange or green bacteria usually mean that somebody is falling down on the job of cleaning the child's teeth. It could also mean that the child is a mouth-breather.

  2. Brown/yellow stain---very likely from antibiotics. The most common antibiotic to stain the surface of the teeth is Amoxicillin. A single dose may cause a yellow to brown film to form on the teeth in some children. The stain may disappear partially or altogether once the prescription of antibiotics is finished. If it bothers you, the parent, the stain can be readily removed, even for children under two years of age.

  3. Black stain---very often this stain is caused by chewable- or liquid-iron supplements, or even multiple vitamins with added iron. This stain polishes off easily. Some populations naturally form a black line on the teeth at the gums lines of all the teeth. It tends to reform rather quickly after removal by the dentist. Where it comes from we do not know. But, we do find that these patients seem to develop few dental cavities.

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Gastroesophageal Reflux - Effect On Teeth

 

Guide for Parents Whose Children Have Dental Signs of GER

(Gastroesophageal Reflux)

The effect of GER on the teeth:

When stomach acid rises into the mouth, the teeth can be affected.  We have observed areas of dental corrosion in your child’s teeth.  This takes on the form of “reverse architecture” in that what were once cusp tips are now areas of moon cratering where parts of the teeth may appear scalloped out and be sensitive to cold foods and touch.  These erosion areas can become quite deep and in some instances will cause fillings to be washed out or will erode into teeth exposing the nerve or make untreated cavities worse.

    What to do now:
  1. Suggested dietary changes to help reduce reflux:
    • Avoid juices (especially o.j. with pulp), carbonated, sports drinks and water with acid added like Vitamin water.
    • Read the label.  Look for acetic, phosphoric or other acids.
    • Chew gum flavored mainly with xylitol, a naturally occurring sugar substitute, e.g.: Spry® which is 100% xylitol
    • Use hard cheese as a snack or snack chaser, the calcium neutralizes acid
    • Avoid fried & spicy foods & pickles & vinegar
    • Avoid overeating (supersizing)
    • Don’t lie down immediately after eating
    • NO MINTS, PEPPERMINT or SOUR CANDIES (Skittles, War Heads, Altoids…)

    KEEP IN MIND: normal saliva pH greater than 6.3 or just about neutral like plain water after eating  acidity in the mouth drops to about  pH 3.5 because the bacteria create acid from the food saliva usually neutralizes that acid very quickly unless the food supply, for instance lots of sports drink is constantly being replenished remineralization (dissolving) of enamel begins at about pH 5.5!

  2. Elevate head of bed with a 2 x 4.
  3. Nothing to eat for 2 hours before bedtime. It takes two hours to clear the stomach.
  4. Swish water and rinse after a bad taste, or acid food and drink.  DO NOT BRUSH as that will remove recently dissolved enamel!
  5. Review resources for an in-depth understanding of GER:
    • Articles on the internet (type GER or GERD into the search engine)

    The National Digestive Diseases Information Clearinghouse website has three sites with excellent information related to GERD in general; in children and adolescents; and infants:
    http://digestive.niddk.nih.gov/ddiseases/pubs/gerd/index.htm
    http://digestive.niddk.nih.gov/ddiseases/pubs/gerinchildren/index.htm
    http://digestive.niddk.nih.gov/ddiseases/pubs/gerdinfant/index.htm
     

  6. Work with your child to assist him/her to be able to accurately describe:
    • What it feels like when reflux occurs
    • How often reflux occurs
    • What time of day it occurs (bedtime, after meals, upon awakening, etc.)
    • Whether certain food seems to be related to refluxing (make a list)
    • How long has he/she been aware of refluxing

    Once you have gathered all the information you can, keep a diary of symptoms and IF symptoms, in addition to dental erosion are present:

  7. Contact your child’s pediatrician for an evaluation of the need for diagnostic tests and/or medication.

Please keep me informed of the outcome of any tests and the effect of any medication that is prescribed for your child.

Long term medical and dental risks: If untreated, GE Reflux can predispose you to esophageal (throat) problems in adulthood.  There is higher risk for tooth decay as saliva cannot neutralize the strong acid.

 

Click here for a printable version of "Guide for Parents Whose Children Have Dental Signs of GER (Gastroesophageal Reflux)"

Hypocalcified Teeth

Teeth occasionally experience a disturbance during development that results in the enamel developing atypically. It is usually observed as a discoloration: white, yellow or brown. We most commonly see it on the first permanent molars and central incisors (two front teeth), although it can happen to any of the teeth.

What Is Pulp Therapy?

The pulp of a tooth is the inner central core of the tooth.  The pulp contains nerves, blood vessels, connective tissue and reparative cells.  The purpose of pulp therapy in pediatric dentistry is to maintain the vitality of the affected tooth (so the tooth is not lost) until the permanent tooth is ready to erupt. 

Dental caries (cavities) and traumatic injury are the main reasons for a tooth to require pulp therapy.  Pulp therapy is often referred to as a "nerve treatment," "children's root canal," "pulpectomy" or "pulpotomy."  The two common forms of pulp therapy in children's teeth are the pulpotomy and pulpectomy. 

A pulpotomy removes the diseased pulp tissue within the crown portion of the tooth.  Next, an agent is placed to prevent bacterial growth and to calm the remaining nerve tissue.  This is followed by a final restoration (usually a stainless steel crown). 

A pulpectomy is required when the entire pulp is involved [into the root canal(s) of the tooth].   During this treatment, the diseased pulp tissue is completely removed from both the crown and root.  The canals are cleansed, disinfected and in the case of primary teeth, filled with a resorbable material.  Then a final restoration is placed.  A permanent tooth would be filled with a non-resorbing material.

What’s The Best Toothpaste For My Child?

Tooth brushing is one of the most important tasks for good oral health. Many toothpastes, and/or tooth polishes, however, can damage young smiles. They contain harsh abrasives which can wear away young tooth enamel. When looking for a toothpaste for your child make sure to pick one that is recommended by the American Dental Association. These toothpastes have undergone testing to insure they are safe to use and that the ingredients work as advertised.

Remember, children should spit out toothpaste after brushing to avoid getting too much fluoride. If too much fluoride is ingested, a condition known as fluorosis can occur. If your child is too young or unable to spit out toothpaste, consider providing them with a fluoride free toothpaste, using no toothpaste, or using only a "pea size" amount of toothpaste.

Why Does My Child Grind His/Her Teeth?

As many as 80-90% of young children grind (brux) their teeth at night. Many children also brux during the day. The only directly related cause known for bruxing is that Children with a combination of allergies and severely restricted airways will brux. The jaw movement opens the eustachion tube and gives relief. This would be similar to yawning while driving to Lake Tahoe in order to alleviate the pressure in one’s ears. We know that animals grind their teeth to keep them sharp and that females are more likely to brux than males. Interestingly, there is a hereditary component to bruxing. In children, the anatomy of the temperomandibular joint (TMJ) allows easy movement of the bottom jaw (mandible). These movements become harder to make as the TMJ matures with age. All the other explanations for bruxing are conjecture.

Interestingly, bruxism, bed wetting, sleep talking, nocturnal muscle cramping, drooling while sleeping, and starting to sleep though the night at a later age are all associated.

Children usually grow out of this problem by age ten without causing any permanent damage. If the problem persists into the early teens and the dentist recognizes signs of unusual wear to the permanent teeth, preventive measures can be taken to prevent future damage. Treatment may involve a plastic nightguard for nighttime wear and/or bio-feedback therapy.

Remember, bruxism in young children does not always mean that damage is occurring or that dental problems will occur later in life.

Thumb Sucking

Sucking is a natural reflex and infants and young children may use thumbs, fingers, pacifiers and other objects on which to suck. It may make them feel secure and happy or provide a sense of security at difficult periods. Since thumb sucking is relaxing, it may induce sleep.

Thumb sucking that persists beyond the eruption of the permanent teeth can cause problems with the proper growth of the mouth and tooth alignment. How intensely a child sucks on fingers or thumbs will determine whether or not dental problems may result. Children who rest their thumbs passively in their mouths are less likely to have difficulty than those who vigorously suck their thumbs.

Children should cease thumb sucking by the time their permanent front teeth are ready to erupt. Usually, children stop between the ages of two and four. Peer pressure causes many school-aged children to stop.

Pacifiers are no substitute for thumb sucking. They can affect the teeth essentially the same way as sucking fingers and thumbs. However, use of the pacifier can be controlled and modified more easily than the thumb or finger habit. If you have concerns about thumb sucking or use of a pacifier, consult your pediatric dentist.

A few suggestions to help your child stop thumb sucking:

Harold's Hideaway Thumb
by Harriet Sonnenschein, Jurg Obnzt (Illustrator), Jurg Obrist (Illustrator)
David Decides About Thumbsucking - A Story for Children, a Guide for Parents
by Susan Heitler Ph.D., Paula Singer (Photographer)

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What Is The Best Time For Orthodontic Treatment?

Developing malocclusions, or bad bites, can be recognized as early as 2 to 3 years of age. Often, early steps can be taken to reduce the need for major orthodontic treatment at a later age.

Stage I – Early Treatment: This period of treatment encompasses ages 2 to 6 years. At this young age, we are concerned with underdeveloped dental arches, the premature loss of primary teeth, and harmful habits such as finger or thumb sucking. Treatment initiated in this stage of development is often very successful and many times, though not always, can eliminate the need for future orthodontic/orthopedic treatment.

Stage II – Mixed Dentition: This period covers the ages of 6 to 12 years, with the eruption of the permanent incisor (front) teeth and 6 year molars. Treatment concerns deal with jaw malrelationships and dental realignment problems. This is an excellent stage to start treatment, when indicated, as your child’s hard and soft tissues are usually very responsive to orthodontic or orthopedic forces.

Stage III – Adolescent Dentition: This stage deals with the permanent teeth and the development of the final bite relationship.

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EARLY INFANT ORAL CARE

Parental Guidelines for Preparing Your Child for Their First Dental Visit

We recommend that you and your child visit our office well before your child's second birthday. You can make the first visit to the dentist enjoyable and positive. Your child should be informed of the visit and told that the dentist and their staff will explain all procedures and answer any questions. The less fuss and anxiety concerning the visit, the better. We examine most children, under 3 1/2, in their parent's lap.  We will discuss findings and how to keep your child's teeth clean and healthy.  A follow-up visit may be anywhere from a few months to over one year depending on the findings of the exam.

It is best if you refrain from using words around your child that might cause unnecessary fear, such as needle, pull, drill or hurt. Pediatric dental offices make a practice of using words that convey the same message, but are pleasant and non-frightening to the child. See Parent Guidelines.

When Will My Baby Start Getting Teeth?

Teething, the process of baby (primary) teeth coming through the gums into the mouth, is variable among individual babies. Some babies get their teeth early and some get them late. In general the first baby teeth are usually the lower front (anterior) teeth and usually begin erupting between the age of 6-8 months. See Eruption of Your Child’s Teeth for more details.

If Teeth Could Talk - Is Teething Painful

Teething for an infant or a toddler is not always painful. As early as one or two months before a tooth actually appears, a child may experience discomfort. This may help to explain why an infant may demonstrate excessive agitation when there is no known cause. A teething child may wake up crying in the middle of the night and require cuddling, rocking and even a mild pain reliever. For another child, teeth may suddenly appear in the mouth at appropriate intervals without any sign that the teeth were ready to erupt.

Some children tend to collect increased fluids in their head and neck around teething time. There is speculation that this retained fluid increases the child’s susceptibility to infection, elevated temperature, head colds, and/or diarrhea. Such changes in a child’s health may coincide with the eruption of the large, first primary molars that appear at about one year of age. However, it is important that the above symptoms not always be blamed on teething. Any of these symptoms that are excessively prolonged should be discussed with the child’s medical doctor.

A child may be soothed by teething rings, especially the one’s that can be chilled in the refrigerator. A frozen mini bagel can also work well. Another child may refuse all aids. Often, rubbing the infant’s gums with a clean finger or wet washcloth may be comforting, and commercial (over the counter) topical anesthetics may also be helpful. However, some babies object more to the taste and numbing sensation of the medicine than to the teething itself.

The period of teething is highly variable. The first tooth usually emerges, in the lower front, at about 6 to 10 months of age, but it can be as early as 4 months and as late as 18 months. This eruption pattern is an inherited characteristic and in fact so might be the susceptibility to teething discomfort.

Remember, teething is a natural process. When the tooth appears, the symptoms vanish and it is time to start brushing the tooth. That will be the topic of the next column.

Baby Bottle Tooth Decay (Early Childhood Caries)

One serious form of decay among young children is baby bottle tooth decay. This condition is caused by frequent and long exposures of an infant’s teeth to liquids that contain sugar. Among these liquids are milk (including breast milk), formula, fruit juice and other sweetened drinks.

Putting a baby to bed for a nap or at night with a bottle other than water can cause serious and rapid tooth decay. Sweet liquid pools around the child’s teeth giving plaque bacteria an opportunity to produce acids that attack tooth enamel. If you must give the baby a bottle as a comforter at bedtime, it should contain only water.  If your child won't fall asleep without the bottle and its usual beverage, gradually dilute the bottle's contents with water over a period of two to three weeks. 

After each feeding, wipe the baby’s gums and teeth with a damp washcloth or gauze pad to remove plaque. The easiest way to do this is to sit down, place the child’s head in your lap or lay the child on a dressing table or the floor. Whatever position you use, be sure you can easily see into the child’s mouth.

Sippy cups

Sippy cups should be used as a training tool from the bottle to a cup and should be discontinued by the first birthday. If your child uses a sippy cup throughout the day, fill the sippy cup with water only (except at mealtimes). By filling the sippy cup with liquids that contain sugar (including milk, fruit juice, sports drinks, etc.) and allowing a child to drink from it throughout the day, it soaks the child’s teeth in cavity causing bacteria.

 

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PREVENTION

5 Things You Didn't Know About Teeth

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7 Steps to Protect Your Child's Teeth

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Care Of Your Child’s Teeth

Plaque is a sticky film in which bacteria breed; it grows on teeth.  The bacteria take about 24 hours to mature to the point where they can make acid.  The acid causes cavities and makes the gums bleed.  Children's teeth should be cleaned as soon as they erupt into the mouth.  Use a wet wash cloth or a small child-size toothbrush.  Use a small pea-size amount of fluoride toothpaste starting about age 2.  Use a wet washcloth or the Infa Dent™, at bath time, to clean your infant's gum pads and/or newly emerging teeth.

Children should be encouraged to brush their teeth, by themselves, in the morning after breakfast.  At night, an adult should brush and as necessary, floss the child's teeth.  The child will have the ability to brush, on their own, at between 7 to 10 years of age.  Each child is different.  Your pediatric dentist and staff can help you determine when the child has the skill level to brush properly.

Proper brushing removes plaque from the inner, outer and chewing surfaces.  When teaching children to brush, place the toothbrush at a 45 degree angle; start along the gum line with a soft bristle brush in a gentle circular motion.  Brush the inner surfaces of the bottom molar teeth first.  Finish the inner surfaces of the bottom teeth, then the outer and chewing surfaces.  Repeat the same method on the top teeth.  Finish by brushing the tongue to help freshen the breath and remove bacteria.

Flossing removes plaque between the teeth where a toothbrush can’t reach. Flossing should begin when any two teeth touch. You should floss the child’s teeth until he or she can do it alone. Use about 18 inches of floss, winding most of it around the middle fingers of both hands. Hold the floss lightly between the thumbs and forefingers. Use a gentle, back-and-forth motion to guide the floss between the teeth. Curve the floss into a C-shape and slide it into the space between the gum and tooth until you feel resistance. Gently scrape the floss against the side of the tooth. Repeat this procedure on each tooth. Don’t forget the backs of the last four teeth.  You may find it easier to use the flossing tool that we will dispense and demonstrate how to comfortably use this on your child. We highly recommend Wild Flossers® by Johnson and Johnson.

Disclosing the plaque enables older children to brush until all the plaque is removed.  A disclosing solution is recommended.

Always look at your child's teeth. Color change could indicate a problem. Watch as new teeth erupt. Keep them clean.  Some medications, such as Amoxicillin® and iron supplements may temporarily stain the surface of the teeth.  The stain is easily removed by a light polishing in our office.  See Why Are There Stains On My Child's Teeth

Permanent teeth are darker (more yellow) in color than primary teeth.  They are denser and made to last a lifetime

Good Diet = Healthy Teeth

Healthy eating habits lead to healthy teeth. Like the rest of the body, the teeth, bones and the soft tissues of the mouth need a well-balanced diet. Children should eat a variety of foods from the five major food groups. Most snacks that children eat can lead to cavity formation. The more frequently a child snacks, the greater the chance for tooth decay. How long food remains in the mouth also plays a role. For example, hard candy and breath mints stay in the mouth a long time, which cause longer acid attacks on tooth enamel. If your child must snack, choose nutritious foods such as vegetables, low-fat yogurt, and low-fat cheese which are healthier and better for children’s teeth.

Hard candies and chewing gum in which xylitol is the main sweetening ingredient are highly recommended. Xylitol is a naturally occurring sugar substitute that encourages remineralization and prevents decay. See Demineralization vs Remineralization.

How Do I Prevent Cavities?

Good oral hygiene removes bacteria and the left over food particles that combine to create cavities. For infants, use a wet gauze or clean washcloth to wipe the plaque from teeth and gums. Avoid putting your child to bed with a bottle filled with anything other than water. See "Baby Bottle Tooth Decay" for more information.

As soon as the child can hold the toothbrush, they should brush their own teeth in the morning, after the parent places toothpaste on the brush.  A parent should brush the child's teeth at night.. Also, watch the number of snacks containing sugar that you give your children.

The American Academy of Pediatric Dentistry recommends six month visits to the pediatric dentist beginning at your child’s first birthday. Routine visits will start your child on a lifetime of good dental health.

Your pediatric dentist may also recommend other measures such as home fluoride treatments.

Plaque

Plaque is a sticky film in which bacteria breed, it grows on teeth. The bacteria take about 24 hours to mature to the point where they can make acid. The acid causes cavities and makes the gums bleed.

Disclosing the plaque enables older children to brush until all the plaque is removed. A disclosing solution is recommended.

Resin Fillings Used To Prevent Cavities


“My child has a cavity?!”
or
“I thought a sealant was to prevent a cavity, then why a resin filling?”

A cavity is by definition a hollow place-- a hole. Often, molar, premolar teeth and the backsides of top front teeth are formed with deep grooves, pits, and fissures. Despite one’s best efforts, the toothbrush bristles cannot reach down to clean out these crevices (see photo). It is warm, dark, and moist at the bottom of these pits, and the acid from bacteria easily begins to soften the tooth enamel as decay begins.

You may have heard about “sealants.” Sealants are supposed to be a protective coating to prevent decay. Some dentists advocate doing the procedure on all permanent molar teeth and many primary molar teeth soon after these teeth erupt into the mouth. However, it seems that not all people need this procedure. In fact, about 80% of children need it in at least one permanent molar and about 10% of children need it in a primary molar.

In this office, we advocate the procedure only when signs indicate that decay is starting or extremely possible to start in a tooth. Then, the tooth receives a mini-resin, “invisible” filling. The “water whistle” (also known to many of you as the “drill”) is used to explore the deep pits, fissures and grooves of the affected tooth and remove any decay that is lurking there. Only the most minimal amount of tooth structure is removed to eliminate any possible decay. This is usually a painless procedure for the child, and no numbing is routinely required. Some children may feel a quick tinge of “cold” when the bottom of the pit is reached and the last bit of decay is removed. Children are always warned of this potential feeling at the appropriate time. The feeling is usually not enough to warrant an injection and the subsequent experience of numbness for hours afterwards.

Approached in this way, the resin will more likely remain for years without recurring decay under the small, conservative, “invisible” mini-filling. These are not the fillings with which most of us are familiar.

We tell the children that these do not “count” as cavities because they could not be prevented. And, when we refer to them as “fillings”, they are not the fillings that most of us are familiar with. They are small, conservative, “invisible” mini, resin fillings.

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Alternative Restorative Technique (ART) For Early Childhood Caries (ECC)

Explanation for Parents

Early Childhood Caries (ECC) is a very aggressive fast-moving type of decay! ECC is a particular challenge to treat due to the child’s limited capacity to understand at this age (age 1 or 2). We are also very limited in the length of time a child will sit still and allow us to work. If the work is significant, our only alternative to treat these cavities and avoid infections, abscesses and extractions used to be general anesthesia in the hospital or sedation in the dental office.

ART is a variety of new techniques designed to slow down or stop the decay and to place temporary fillings as the child is developing so more conventional fillings can be placed. We are buying time and attempting to avoid the hospital treatment or sedation. This technique relies on daily support at home. If we do not have excellent help at home, failure is more likely and we may be faced with the general anesthesia choice and the extensive dental work. These techniques include:

  1. Identification and cessation of the cause of the early caries. Without excellent cooperation at this step in the home all the rest of our efforts will be in vain. We will lose time, increase the costs, and need to do immediate conventional treatment on a worsened condition.

  2. Remineralizing with topical fluoride applications at the office and at home. All the fluoride research conducted during the last 20 years demonstrates that the beneficial effect of fluoride is topical, i.e., we don’t need to ingest it to receive any benefit. And, the fluoride can remineralize areas where the cavity has started. It is healing the cavity.

  3. Removing bulk decay from the cavities with quiet instruments and opening the areas to permit easier cleaning with tooth brushes, floss and toothpicks. Injections of local anesthetic are not required and treatment can be done with the child in the parent’s lap.

  4. Placing temporary fillings where feasible or necessary. We use materials that will inhibit the potential for new, active caries to start.

  5. Monitoring carefully! We recommend follow-up visits at 3-month intervals and placement of fluoride varnish.
    a) If caries is progressing we want to identify that quickly while as many conservative options for treatment as possible are still available.
    b) If we need to modify the program, we want to identify the need and the reasons at the earliest interval possible.

We want to emphasize that if this program if followed correctly, it is highly successful. If the program is not followed adequately it may not be successful and may lead to a delay in treatment and a worsening of the problem. If at any time in the process you feel you cannot fulfill your home care activities that we are requesting, let us know so we can adjust the program to better suit your needs.

Mouth Guards

When a child begins to participate in recreational activities and organized sports, injuries can occur. A properly fitted mouth guard, or mouth protector, is an important piece of athletic gear that can help protect your child’s smile, and should be used during any activity that could result in a blow to the face or mouth.

Mouth guards help prevent broken teeth, and injuries to the lips, tongue, face or jaw. A properly fitted mouth guard will stay in place while your child is wearing it, making it easy for them to talk and breathe.

Ask your pediatric dentist about custom-made and store-bought mouth protectors.

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ADOLESCENT DENTISTRY

Tongue Piercing – Is It Really Cool?

You might not be surprised anymore to see people with pierced tongues, lips or cheeks, but you might be surprised to know just how dangerous these piercings can be.

There are many risks involved with oral piercings including chipped or cracked teeth, blood clots, or blood poisoning. The mouth contains millions of bacteria, and infection is a common complication of oral piercing. The tongue could swell large enough to close off the airway!

Common symptoms after piercing include pain, swelling, infection, an increased flow of saliva and injuries to gum tissue. Difficult-to-control bleeding or nerve damage can result if a blood vessel or nerve bundle is in the path of the needle.

So follow the advice of the American Dental Association: Skip the mouth jewelry.

Tobacco – Bad News In Any Form

Tobacco in any form can jeopardize your child’s health and cause incurable damage. Teach your child about the dangers of tobacco.

Smokeless tobacco, also called spit, chew or snuff, is often used by teens who believe that it is a safe alternative to smoking cigarettes. This is an unfortunate misconception. Studies show that spit tobacco may be more addictive than smoking cigarettes and may be more difficult to quit. Teens who use it may be interested to know that one can of snuff per day delivers as much nicotine as 60 cigarettes. In as little as three to four months, smokeless tobacco use can cause periodontal disease and produce pre-cancerous lesions called leukoplakias.

If your child is a tobacco user you should watch for the following that could be early signs of oral cancer:

Because the early signs of oral cancer usually are not painful, people often ignore them. If it’s not caught in the early stages, oral cancer can require extensive, sometimes disfiguring, surgery. Even worse, it can be fatal.

Help your child avoid tobacco in any form. By doing so, your child will avoid bringing cancer-causing chemicals in direct contact with their tongue, gums and cheek.

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POST OPERATIVE CARE INSTRUCTIONS

Tooth Extraction Instructions

Your child's mouth is expected to heal normally. To assure this, please follow these instructions:

1. Make certain that your child continues to bite on the gauze for 15 to 20 minutes after leaving
our office. This biting pressure stops the bleeding and allows better clotting.

2. Use the extra gauze we have provided when the initial gauze becomes overly wet. Fold the
gauze pad into fourths and place it into the extraction site. Then have your child bite firmly.

3. Bleeding should stop in about 20 to 45 minutes after extraction. A slight oozing of blood for
a day is normal. If it is a problem, have the child continue to bite on the gauze. Call our office if there is excessive bleeding. Sometimes, a little blood mixed with saliva appears to be excessive bleeding. Have your child’s head slightly elevated for sleep and use an old pillow case.

4. The area where the tooth was (extraction site) will turn dark burgundy red and a gray-yellow
spot may appear in the center. This is normal healing. Within 5 to 10 days after extraction, the
area will become pink and look normal again.

5. For one hour following the extraction your child should have nothing to eat or
drink. For the remainder of the day your child should eat soft foods and avoid hot foods and eating on the side of the extraction. (Examples of soft foods are soups, pasta, eggs, oatmeal, yogurt, gelatin, puddings, apple sauce, soft cheeses, mashed potatoes, and creamed spinach). If a front tooth was extracted, avoid foods that need to be incised like chicken or ribs on the bone or corn on the cob.

6. On the day of extraction, your child should not rinse his or her mouth or drink
through a straw because these activities may disturb the clot.

7. Be careful and watch that your child does not accidentally bite or scratch the numb cheek,
tongue and/or lip. It can happen very quickly! The numbness generally lasts one to three
hours.

8. Gentle brushing with warm salt water (1 tsp. salt per 8 oz. glass of water) can begin the morning
following the extraction. A clean mouth will heal more quickly. Continue the rinsing for
several days and longer if there is a problem keeping the area clean.

9. If your child feels discomfort, he or she can have the appropriate dosage of acetaminophen
(Tylenol®) or ibuprofen (Advil® or Motrin®) pain killer if your child is not allergic.

10. Do not hesitate to call our office if you have any concerns or questions: (415) 459-1444

Care After Local Anesthetic

Anesthetic numbs the tissues of the lips, the cheeks, and sometimes the tongue of the area involved.  Children usually do not understand the effects of this local anesthetic and have the tendency to chew or suck the affected area, occasionally causing laceration and swelling of the tissues.  Although this may not be a serious thing, it can be very uncomfortable.  PLEASE watch your child very closely until the numbness disappears: upper jaw 2 hours or so, lower jaw 3 to 4 hours if a block is given or about 1 hour if local infiltration is used.  If the child bites the numb area, it usually occurs shortly after leaving the office.

The following is a recommended book and excellent preparation prior to a filling appointment where an injection will be given:

Going to the Dentist by Anne Civardi

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