Although timing varies widely, babies often begin teething by about age 6 months. The two bottom front teeth (lower central incisors) are usually the first to appear, followed by the two top front teeth (upper central incisors). As a rule of thumb children should have 20 teeth by the age of three. Many parents believe that teething causes fever and diarrhoea, but this isn’t true. Teething can cause signs and symptoms in the mouth and gums but not elsewhere in the body. Classic signs and symptoms of teething include drooling and grumbling, chewing on solid objects, irritability or crankiness and sore or tender gums.
- Rub your baby’s gums with a clean finger or moist gauze
- Offer a teething ring
- If a bottle seems to do the trick, fill it with water not juice
- Don’t give your baby a frozen teething ring as contact with extreme cold can be harmful
- Try hard foods. If your baby is eating solid foods, you might offer something edible for gnawing such as a peeled and chilled cucumber or carrot but be careful that any pieces that break off might pose a choking hazard
- Always wipe away drool from around the mouth
The return to school can be a great time to start good habits and make them part of a healthy routine for children. Getting to bed on time and structured meals are much easier to achieve during school term. Planning lunches and bed time are important opportunities to consider habits for caring for children’s teeth. Healthy teeth in children result from twice daily brushing with an appropriate toothpaste and avoiding sugary snacks between meals. Some children will begin training for contact sports for the first time this September and teeth need protection from injury. Many parents will be filling out school insurance forms and should consider insurance for dental injuries out of school hours. Here are some tips to help with the new school term.
Children’s teeth need to be brushed twice daily. The benefits of this practice come not just from the removal of bacteria from the teeth but also through exposure to fluoride in toothpaste. Brushing last thing at night it very important. When children sleep their mouths become dry. Teeth are more vulnerable to decay in a dry mouth than in a mouth that has saliva flowing through it. One great benefit of brushing last thing at night is that the teeth are covered in a slurry of fluoride toothpaste for the night. This helps to harden the teeth which prevents tooth decay. Children under the age of 7 should have their teeth brushed by an adult because they typically lack the dexterity required to do it properly. Remember to spit and not to rinse; to leave the toothpaste on the teeth for as long as possible.
Lunch boxes can be tricky if you have a fussy eater. Some children won’t eat bread. There are plenty of alternatives such as wraps, pitta breads and bagels. Try to keep the fillings savoury and avoid chocolate spreads and jam. For little break consider a piece of cheese or some fruit and avoid biscuits or dried fruits. Milk and water are the safe drinks for teeth. One serving of juice is enough for one day so a bear that in mind if your child takes juice to school.
If your child is starting new contact sports at school be sure they have a mouthguard. Even children who still have their baby teeth need protection. Boil and bite mouthguards are available from sports shops and pharmacies. We also have them available at the practice. They come in a pack and are moulded to the teeth once they have been softened in some hot water. These mouth guards are not always as comfortable as a one made by a dentist however, they make a more practical and less expensive option while children are growing and when they have adult teeth appearing and when primary teeth are exfoliating.
My final tip is about filling in insurance forms for your child through school. Always enquire is it possible to cover injuries outside school hours? This is often very easy and cheap to include on the policy. Then, if your child has a dental injury at home in the evening or at a weekend, the treatment costs will usually be covered. It has been a real relief for some parents of my practice in the past to find that the insurance covered their children’s dental injuries.
Dental fear is a common problem in both Irish children and adults. Not surprisingly, dentally anxious children are more likely to become anxious adults. Fear often prevents people from accessing routine care. It may take severe toothache before a parent seeks dental care for their child. Once dental pain is experienced, children are much more likely to be fearful in the future. This is why visits should start early- “first tooth first visit”.
The most natural instinct a parent will have is to reassure their child. However, this can sometimes make the child think something bad is going to happen, even when it is not. Good communication is really important to help prevent dental fear in children. Getting to know your dentist through regular check-ups helps with that.
For children with more serious anxiety inhalation sedation or “laughing gas” can help them remain calm during treatment. General anaesthetic is where a child is put to sleep for dental care. This is a reliable and safe way of ensuring young or fearful children have high quality dental care with minimal distress. It is important for parents to be aware of how children can pick up on their anxieties in the dental environment.
Dental decay is the most common chronic disease of childhood and is a preventable disease. Flossing helps prevent the development of cavities between teeth where toothbrushing cannot reach. Over 50% of children in non-fluoridated areas (fluoride added to household water) experience decay by their 5th birthday. There is a strong link between a child’s general health and wellbeing and their dental health. Frequently children get used to having discomfort and don’t complain of dental pain. Younger children or children with communication difficulties may not verbalise what is wrong. The first signs of problems may include that child being off their food, sleeping poorly or just being out of sorts. The following are some of the effects of decay in children’s teeth:
- Pain, distress and disruption to family life
- Infection, dental abscesses and facial swellings
- Bad breath
- Discomfort eating
- Difficulty sleeping or waking at night
- Poor growth and failure to thrive
- Poor socialisation and concentration at school
- Diminished quality of life
- Dental anxiety and phobias often develop after children have toothache
- Crowded teeth, impacted teeth and orthodontic problems due to early loss of baby teeth
- Decay in primary teeth often makes decayed adult teeth more likely
- Need for hospital admission and general anaesthesia
- Rarely children die from complications of dental infection
The curvy shape of baby molars makes them especially vulnerable to cavities in the spaces between the teeth. These molars also have thin enamel and large nerve spaces. This means that when decay starts it spreads rapidly to the nerve of the tooth. Therefore, pain and infection may develop very soon after decay starts. The spaces between back teeth often gather foods like fibres from meat or fruit. Once the space starts to trap food, toothbrushing alone will not be enough to remove the risk of a cavity starting. Flossing is the only reliable way to clean this area. Often this type of cavity will not be visible for many months. It is only by taking x-ray pictures that the decay can be picked up. Once the cavities are visible to the naked eye they usually require more complex, invasive and costly treatments to put the problem right. So flossing can help you save on your child’s dental expenses.
Cavities between back teeth are not always amenable to placement of fillings in baby molars. If the decay is too close to the nerve of the tooth, the tooth may require a crown or “silver cap” and “baby root canal treatment” pulp therapy to keep it in the mouth pain and infection free. These treatments require a tooth to be numbed with local anaesthetic or an injection. Wouldn’t it be better to prevent the cavities from starting in the first place?
Not all children need to have their teeth flossed. It is generally recommended to start flossing teeth once there are molars touching each other. If the spaces between the back teeth are open then there is no need to worry about flossing. The best way to be sure is to arrange a check-up and take professional advice. Once parents have received instruction on flossing and children have gotten used to the routine it shouldn’t take longer than a few seconds. I normally recommend flossing 5 out of 7 nights; take Friday and Saturday nights off.
Injuries to the mouth and teeth in children and adolescents are common. Many of these injuries occur during sporting activities and are preventable. Children and adolescents are a very vulnerable group. Injury to developing teeth and gums can cause lasting effects which can require complex and expensive treatment to fix over many years. Participation in contact sports carries a high risk of injury to the mouth and teeth. Wearing a properly fitting mouthguard for sports can really help to reduce the chances of damage to the teeth and jaws. Many injuries happen at school and during sport, therefore it is critical that proper policy exists, on the use of mouthguards to minimise the damage that can happen. Schools sporting associations and clubs have a responsibility to ensure that dental injuries are prevented.
Regardless of how young children are when they begin to play contact sports, protection for their teeth is still important. All contact sports carry a risk of damage to the mouth and teeth; football is no exception. Research has shown that wearing a mouthguard can prevent up to 90% of injuries to the mouth and teeth. Wearing a mouthguard absorbs and deflects the force of a blow to the mouth. It shields the lips, gums and tongue from cuts and lacerations. It stops the top and bottom teeth crashing together during impact and it gives support to the facial bones which reduces the chance of fracturing the jaws.
The roots of the adult front teeth are short and thin when they first appear in the mouth. It takes 3-4 years for an adult front tooth to mature; the root grows in length and width. A blow to an immature tooth can easily stop the tooth from developing further. Short thin roots often snap and break over time. Conventional treatment often doesn’t work. The prevention of injuries in this age group is much simpler than cure!
Protrusive front teeth or teeth that stick out are often very vulnerable to knocks and bangs. Research has shown that they are significantly more prone to injury. In some cases if the upper teeth are very proclined (stick out a lot), the lower lip may not stretch far enough to cover and protect them. Without the protection of the lower lip the upper incisor teeth are even more at risk. In a case like this it may be necessary to correct the position of the front teeth to help protect the teeth from injury. This type of correction would normally be carried out by a specialist in orthodontics.
The solution to these potential injuries is to use a mouthguard for all contact sports. Parents are often unsure about which type of mouthguard to get and are confused because there can be a large variation in cost between the different varieties. There are three different types of mouthguard. The first, a “stock mouthguard” is one that is bought over the counter and does not require any adjustment or moulding. They are made from rigid plastic and are designed to be held between the teeth. They are the least expensive type of mouthguard however, it can be difficult to mouth breathe or to speak while holding the guard in place. They are not very comfortable to wear and as a result they tend to stay in sports bags and don’t get worn. This type of mouthguard offers the least reliable protection in the event of an impact or collision.
The other types include the “boil and bite” and the custom made mouthguards. “Boil and bite” mouthguards are also bought over the counter in sports shops or pharmacies. They can be softened in hot water first and are then moulded around the teeth to provide a better fit. The research on their effectiveness has shown varied results regarding the protection they offer. Comfort is important because when a mouthguard is not easy to wear, children will simply avoid using them. Boil and bite mouthguards are not as comfortable to wear as one made by a dentist. The gold standard mouthguard is a custom made type. This type involves going to a dentist, having a putty mould taken of the teeth. The mouthguard is then manufactured exactly to fit in a laboratory. This type has the best track record for comfort and protection.
Orthodontic treatment often involves frequent changes to the mouth and teeth. Braces do not provide protection for the teeth from injury or displacement. Brackets on the teeth can cause painful lacerations and cuts to the gums on impact. Custom made mouthguards can be modified to accommodate the brackets on the teeth. The down side of a custom made mouthguard is that they can require replacement up to every six months. Alternatively the “boil and bite” types can provide a cheaper alternative until treatment is finished. A dental injury during orthodontics can seriously compromise and or delay the course of treatment.
On the 14th of April this year the GAA passed a motion on the use of mouthguards. It will become mandatory to wear a mouthguard for football games and training sessions. The rule comes into effect from 2013 for players up to and including minor level. This is a very positive step in the right direction!
Almost one third of three year olds in Ireland suffer from dental decay. By the age of 5 this figure increases to 40% in areas where there is water fluoridation and 55% where the water is not fluoridated. Preschool children who develop dental decay are vulnerable to pain, infection and dental anxiety. Management of decay in young children often requires specialist care and facilities, including access to general anaesthetic. Whilst dental disease is preventable, it is an inevitable risk of modern life as we know it. The prevention of dental disease is a responsibility that parents of young children need to be mindful of.
Fluoride toothpastes have been shown to be an effective way of reducing the risk of cavities. There are however, problems associated with fluoride ingestion in toddlers and infants. The need for cavity prevention should always be weighed carefully against the risk of over exposure to fluoride. This type of risk assessment in young children should ideally be carried out by an appropriately qualified dental professional.
Since the introduction of commercially available fluoride toothpastes in the 1970s, there has been a significant decline in dental decay across the industrialised world. Whilst this reduction in dental decay reached a plateau in the 1990s, toothpastes still play an important role in cavity prevention worldwide. The addition of fluoride to public water supplies is an emotive issue. There are strong opponents to this public health measure. In contrast with water fluoridation, the use of fluoride toothpastes as a way of protecting children’s teeth meets with better social and cultural acceptance.
There are many different types of toothpaste on the market and approximately 95% of those contain fluoride. There are a number of fluoride free types available. Under EU directive 76/768/EEC, toothpastes are classified as cosmetic products. Under another EU directive toothpastes must display the concentration of fluoride. Whereas previously the ingredients were shown as percentage of volume, it is now accepted that the most effective way of informing people about the fluoride concentration is in ppm (parts per million). Most adult toothpastes contain around 1500 ppm fluoride. It is necessary to have a prescription for concentrations any higher than this. The efficacy of adult strength toothpastes is well established. The confusion arises when it comes to low fluoride or children’s toothpastes.
Young children often swallow most if not all the toothpaste on the brush. In fact most children less than 4 years are not able to spit out properly. Children under 3 years of age who ingest toothpaste are at risk of a condition called fluorosis affecting the front permanent incisors. Fluorosis can vary from minor white spots to unsightly yellow brown discolouration of the enamel. The remaining teeth at the back of the mouth do not complete development until the age of 7 years therefore, fluorosis can also affect these teeth. Fluorosis is mainly an aesthetic issue meaning that the critical period is 0-3 years. Fluoride toxicity leading to acute poisoning is most commonly associated with unsupervised young children eating tubes to toothpaste.
In response to concerns over dental fluorosis and fluoride poisoning, some manufacturers now market low fluoride “children’s toothpastes” or “paediatric” formulations. Whilst this would seem like a sensible solution to the problem, the scientific evidence for the effectiveness of these pastes is weak. The problem is that children who use a low fluoride toothpaste are at significantly higher risk of dental decay. It is useful to think of toothpaste as a drug. If you wouldn’t allow your child play with the paracetamol, then why would you leave them unsupervised with the toothpaste tube?
Dos and Don’ts for Little Teeth
Life would be very dull if we couldn’t enjoy an ice cream or a piece of chocolate from time to time. There is plenty of evidence to support that when children brush twice daily with fluoride toothpaste, it is possible to have treats in moderation without developing new cavities. Yet there are still some dietary habits which consistently lead to severe decay in paediatric dental patients. Different age groups are more susceptible to certain risky habits. Modern dietary counselling places a positive emphasis on good food habits rather than bad foods.
Up to the age of three or four many children drink from beakers, bottles and sippy cups. Dental decay in this age group is common and poses unique challenges in dentistry. Firstly children at this age may struggle to cope in the dental chair and may lack the co-operation needed to accept local anaesthetic safely. Untreated decay in baby teeth can cause pain and infection and the techniques used to fix these problems differ for children. The approach to preventive care in children is also very specific. These unique challenges may require the care of a Paediatric Dentist in a specialised or hospital setting. Dental decay in children this young often progresses rapidly therefore, pain and infection can come about in a short space of time.
The issue with sippy cups, beakers and bottles is not just what they contain but the way they are used. Bottles taken to bed at night being a case in point; When infants fall asleep with a bottle of formula or juice several factors come together to make this a high risk habit. Below the tongue are ducts of salivary glands which help bathe and cleanse the teeth. If a child has a bottle in their mouth the tongue covers these ducts and prevents saliva from protecting and cleaning the teeth naturally. Our mouths become a little dryer naturally at night. This function helps to prevent us from drooling. This makes the teeth much more vulnerable. Beakers also encourage children to stay drinking for longer periods during the day meaning that whatever they contain it is in contact with the tooth surfaces for longer. This age group typically develops decay on the smooth surfaces of the front teeth.
Good habits include:
- Early weaning from the bottle
- Clean teeth last night and after feeds
- Get your child used to plain water in the bottle and beaker
Frequent snacking between meals on biscuits, cereal bar snacks and dried fruit is common issue resulting in problems in this age group. All of the above foods contain a lot of sugars but most importantly they have a tendency to stick to and coat the surfaces of teeth making the sugar stay around for longer.
Good habits in this age group include:
- Keep food intake to no more than 5 times a day
- Rinse with water after meals to wash off the food particles and sugars from the teeth
- Confine intake of sweets and treats to after meal times only
- One serving of juice is enough in any day
- Water and milk are the only safe drinks
Confectionary and treats are nice rewards to enjoy and it is possible with good habits to have them and remain dentally fit and healthy.
Breastfeeding and tongue ties
Tongue-tie is a problem that occurs in babies who have a tight piece of skin between the underside of their tongue and the floor of their mouth. The medical name for tongue-tie is ankyloglossia, and the piece of skin joining the tongue to the base of the mouth is called the lingual frenulum. It can sometimes affect a baby’s feeding, making it hard for them to attach properly to their mother’s breast. The following article explains tongue-tie and the problems it can cause, and describes a quick and painless procedure to snip the skin, known as tongue-tie division, which should be considered if your baby is affected.
Tongue-tie is a birth defect that affects 3-10% of newborn babies. It is more common in boys than girls. Normally, the tongue is loosely attached to the base of the mouth with a piece of skin or the lingual frenulum. In babies with tongue-tie, this piece of skin is unusually short and tight, restricting the tongue’s movement. Many tongue ties cause no breastfeeding problems however, for some nursing mothers and infants it can lead to problems latching, sore nipples, and poor infant weight gain.
Successful breastfeeding depends on a complex interaction between mother and child. Where there are difficulties it is important that skilled breastfeeding support is available. Where a tongue tie is identified as a cause of problems with nursing, there are advantages to treating the condition early such as allowing mothers to continue to breastfeed rather than having to depend on formula. In new born infants tongue tie correction does not usually require a general anaesthetic unlike tongue tie correction in older children.
To breastfeed successfully, the baby needs to latch on to both breast tissue and nipple, and the baby’s tongue needs to cover the lower gum so the nipple is protected from damage. Babies with tongue-tie are not able to open their mouths wide enough to latch on to their mother’s breast properly. They tend to slide off the breast and chomp on the nipple with their gums. This is very painful and the mother’s nipples can become sore, with ulcers and bleeding. Some babies feed poorly and get tired, but they soon become hungry and want to feed again. In most cases, these feeding difficulties mean the baby fails to gain much weight.
If your feeding specialist identifies that breastfeeding is affected by a tongue tie then it will need to be divided. Tongue-tie division involves cutting the short, tight piece of skin that connects the underside of the tongue to the floor of the mouth. It is a simple and painless procedure that usually resolves feeding problems straight away. The National Institute for Health and Clinical Excellence (NICE) supports the use of tongue-tie division, as it is safe and there is evidence that it can improve breastfeeding.
In babies only a few months old, division of tongue-tie is usually performed without any anaesthetic (painkilling medication), or with a local anaesthetic that numbs the tongue. A general anaesthetic is usually needed for older babies with teeth, which means they’ll be asleep during the procedure. You can start feeding your baby immediately afterwards. Some babies sleep through it, while others cry for a few seconds. In small babies, being cuddled and fed are more important than painkillers. If you’re concerned about your baby’s feeding, speak to your infant feeding specialist, lactation consultant, health visitor, midwife or GP.
How to save a tooth: The first thing to do is ask if it is a baby tooth or an adult tooth? Baby teeth should never be replanted. This is because they can damage the developing adult tooth. Adult teeth on the other hand are very vulnerable out of the mouth. The cells on the root of the tooth can be damaged by chemicals, water and air. Damaged cells will be rejected by the body and the tooth will not survive when replanted. The way the tooth is handled in the first 10 minutes has been shown to be critical in the long term outcome for a tooth. There are 5 key steps to saving a tooth:
- Pick the tooth up by the crown/top and not the root
- Quickly put the tooth under cold running water to clean off any debris
- Replant the tooth in the tooth socket if possible
- Where replantation is not possible place the tooth in fresh milk (never water)
- Get to a dentist immediately
There is often confusion around whether delaying treatment matters for broken and fractured teeth. The outer enamel of a tooth protects a delicate and sensitive inner layer. When that enamel is broken the tooth is vulnerable to bacteria in the mouth which can travel into the nerve inside the tooth. Bacteria can cause the nerve to die in a short time after the injury. It is important not to delay seeking dental care for children who chip and break teeth.
Dental injuries may often cause a tooth to turn grey which can be very unsightly. If a single tooth turns grey the discoloration can be masked for baby teeth. Colour adjustments for adult teeth can be made by bleaching using special techniques.
Whilst dental implants may be a very valuable way of fixing a missing tooth in adults, they cannot be used in growing children or adolescents to replace missing teeth. The problem is that they cannot grow like a natural tooth. This gives the impression that the implant is sinking.
There are a number of specialities in dentistry which deal with trauma. Oral surgeons treat broken facial bones and fractured jaws. Endodontists have specialist training in handling complex dental trauma in adults. Paediatric dentists have advanced training and expertise in treating dental trauma in children.
Do Fruit Juices Cause More Harm Than Good?
Food labelling and clever marketing can make fruit juices, flavoured waters and smoothies seem like healthy options for children. Whilst fruit and vegetables are an important source of vitamins, minerals, fibre and other essential nutrients, fruit flavoured beverages are responsible for a large percentage of the dental problems experienced by Irish infants, children and teenagers.
Sometimes drinks are labelled “no added sugar” and this type of labelling causes a lot of confusion. Whilst the label is not saying anything untrue, the natural sugars and acids in the beverage are still potentially damaging to the teeth if consumed inappropriately; meaning high frequency or prolonged exposure.
The first obvious signs of problems are usually brown spots on the teeth however, by this time the decay can be quite advanced. X-rays are an important way of finding dental disease in children’s teeth because it is often not possible to see on visual inspection alone. Damage from acid can be more difficult to spot. The teeth might become sensitive first or the front teeth might start to look short or ragged.
The key message is make sure your child has a dental home and that they have regular check-ups. When problems are identified early the solution is usually a lot simpler.