from Complete Guide to Your Children's Health 1999 American Medical Association

A healthy, pain-free mouth and teeth are indispensable for your child's overall health and well-being. Strong teeth enable your child to chew easily, speak clearly, and produce that smile you so much love to see. You are responsible for your child's oral hygiene in the early years. You also need to teach the basics of brushing and flossing, take your child to the dentist regularly for checkups and cleanings, and make sure that he or she is eating right.

Primary teeth, or baby teeth, are just as important as permanent teeth. The primary teeth preserve space for the permanent teeth and guide them into position. Primary teeth also encourage normal development of the jawbones and muscles. Baby teeth that become infected or decayed or are lost too early can cause pain, poor eating habits, speech problems, or crooked or damaged permanent teeth. The rate at which children get their first teeth varies greatly, but,
baby teeth usually start coming in when a child is between 5 and 9 months old and continue until about age 2 ½ when all 20 baby teeth are present.

Teething
Just before a primary tooth starts coming in, the gum above the tooth may become swollen or sore. If you rub your finger along the gum, you may feel a bump in the gum over the new tooth or the tip of the tooth itself. A teething child may be fussier than usual and may pull on his or her ears, have a poor appetite, and drool.

To help reduce the discomfort, try giving your child a one-piece teething ring or pacifier. (Teething rings and pacifiers made of more than one piece can break apart and cause choking.) Some are made to be chilled in the refrigerator; the cold can be very soothing. Never dip a teething ring or pacifier in sugar or honey because the sugar can cause tooth decay. Some parents find it helpful to apply a cold, wet washcloth to their child's gums or to rub the gums with their finger. If your child experiences a lot of discomfort, your doctor may recommend giving the over-the-counter pain reliever acetaminophen. Use numbing medicines with caution because they can numb the back of the child's throat and inhibit swallowing.

When they are 3 to 4 months old, babies start producing more saliva than they can swallow, so they often begin to drool. They also begin to put objects in their mouth and bite or chew on them. Drooling and chewing on objects (or rubbing them against the gum) are normal parts of infant development and may not always be a sign of teething. Teething does not cause fever, rash, diarrhea, or other illnesses. If your child has these symptoms, talk to your doctor; they are probably from something other than teething.

When teeth come in:

• Incisors appear at 6 to 9 years.
• Canines appear at 9 to 12 years.
• Premolars appear at 10 to 12 years.
• First molars appear at 6 to 7 years.
• Second molars appear at 11 to 13 years.
• Third molars appear at 17 to 21 years.

PREVENTING TOOTH DECAY
Tooth decay is the leading dental problem in children. Decay occurs when bacteria normally present on the teeth (in a sticky film called plaque) interact with sugars and starches from foods. The bacteria use the starches to produce acid, which softens the enamel on the teeth, causing a cavity.

Teeth cleaning
By age 1, many children already have decaying teeth from exposure to sugary liquids for long periods. Care of the mouth and teeth is essential to prevent tooth decay. You need to thoroughly wipe your baby's gums after each feeding with a damp cloth or piece of gauze to loosen the bacteria that cause cavities. Later, as your child's primary teeth come in (usually between 5 and 9 months of age), brush them at least twice during the day and at bedtime with a small, soft-bristle toothbrush dipped in warm water. The bristles should be made of polished nylon and have a flat brushing surface.
Don't use toothpaste until your child is able to rinse and spit it out (at about age 2 or 3). Even then, use only a small, pea-sized amount.

By the time your child is about 2 or 3 years old, you should begin teaching the child how to brush his or her own teeth at least twice a day. Until the child is about age 6, it's a good idea for you to do the brushing at least once a day. When your child brushes, check such hard-to-reach areas as the inner surfaces of the teeth and the back teeth and do a follow-up brushing when needed. A worn-out toothbrush will not clean your child's teeth; replace the brush about every 3 months. Here are some more tooth brushing tips:

• Use only a pea-sized amount of fluoride toothpaste on the brush.
• Change the position of the toothbrush frequently; it will only clean one or two teeth at a time.
• Brush gently with very short back-and-forth or circular strokes but with enough pressure to feel the bristles against the gum.
• Brushing after every meal is ideal, so try to instill this habit early. But your child should brush thoroughly at least twice every day.
• Supervise bedtime brushing until the child is competent enough to do it alone.
• If your child has any discomfort or bleeding during tooth brushing tell your dentist.
• Begin gently flossing your child's teeth when the permanent ones start coming in. By age 7 or 8, children usually have enough dexterity to do all of their own brushing and flossing.

Ask your dentist or dental hygienist to show you how to properly floss your child's teeth. Here are the basic steps:
1. Break off about 18 inches of floss and wind most of it around one of your middle fingers.
2. Wind the rest around the middle finger of the opposite hand; this finger can take up the floss as you use it.
3. With an inch of floss between your thumbs and forefingers, guide the floss between the teeth.
4. Holding the floss tightly, use a gentle sawing motion to insert the floss between the teeth (see illustration). Don't snap the floss into the gums or you could cut them. When the floss reaches the gum line, curve it into a c-shape against one tooth and gently slide it into the space between the gum and the tooth until you feel resistance.
5. While holding the floss tightly against the tooth, move the floss away from the gum by scraping it up and down against the side of the tooth.
6. Repeat the above steps on the rest of the teeth.

Preventing baby-bottle tooth decay
Never let your babies sleep with a bottle of formula, milk, or juice in his or her mouth because the prolonged exposure to the sugars in these foods can cause your baby's teeth to decay. Baby-bottle tooth decay is the main dental problem in children under 3 years old and can prevent them from developing healthy primary teeth.

When a child is awake, saliva in the mouth helps wash away sugars from food, But during sleep, the baby swallows less often so the sugary liquids remain on the teeth, especially the upper front ones, quickly leading to decay. Its all right to let your baby fall asleep while feeding, but take the bottle away once you put the baby in the crib. You can also try these other soothing ways of helping your baby get to sleep:

• Rub your child's head or back.
• Read or tell a story.
• Sing or play soft music.
• Hold or rock your baby.
• Put a musical toy or mobile near the bed.
• Offer a blanket, soft toy, or pacifier.

Preventing tooth problems:
Most cavities and tooth injuries can be prevented with a few simple measures. Here are some tips for keeping your child's teeth strong and healthy:

• Find out the level of fluoride in your water supply. If the water is not fluoridated, ask your pediatrician or dentist about fluoride supplements.
• Clean your infant's gums with a wet cloth or gauze after feedings and at bedtime, even before the baby teeth come in.
• If your child uses a pacifier, make sure it's a type recommended by your doctor; never dip the pacifier in anything sweet before giving it to your child.
• Once your baby's teeth start coming in, brush them gently with a small, soft-bristled brush and water only at least twice daily and at bedtime. When your child is 2 years of age, use a small (pea-size) amount of fluoride toothpaste on the brush.
• Teach your child to drink from a cup as soon as he or she can sit up alone, usually between 6 months and a year.
• Wean your child from the bottle by age 1.
• Instill the habit of brushing with fluoride toothpaste twice a day and flossing once a day.
• If you give your child gum and soda pop, make sure they are sugarless.
• Encourage your child to stop thumb-sucking by age 2. By age 5, thumb-sucking can cause tooth misalignment and malformation of the roof of the mouth.
• Make sure your child wears protective equipment such as a mouth guard and helmet when playing sports.
• Discourage your child from smoking cigarettes or using chewing tobacco.
• Don't let your child chew on pens and pencils; the teeth can chip and crack. Chewing on ice can cause a tooth to fracture.
• If your child grinds his or her teeth (usually while sleeping), ask your dentist about a protective mouth guard (called a bite guard) to wear during sleep.

Here are some things you shouldn't do:

• Don’t let your child sleep with a bottle of formula, milk, juice, or any other drink containing sugar. If you must give your baby a bottle for comfort, fill it with water.
• Don't use a bottle of milk or juice as a pacifier during the day.
• Don't let your toddler carry around and suck on a bottle filled with milk, juice, or other sugary liquids.
• Don't allow your child to snack on sweets excessively.
• Don't give your child starchy foods such as crackers, sticky foods such as raisins or jelly beans, or fruit or fruit juices before bedtime. These foods stay on the teeth and promote tooth decay.

A healthy diet:
For healthy teeth, children need to eat a nutritious, well-balanced diet (see page Ill) that includes lots of whole-grain breads and cereals, vegetables, and fruits. Your child also needs to consume all the essential vitamins and minerals. Calcium is especially important for building strong teeth.
Dairy products, such as milk and yogurt, are excellent sources of calcium. After your child is 3 years old, you can begin giving him or her low-fat or fat-free dairy products, such as skim milk, so he or she gets the calcium without excessive calories from fat.

The sugar in sweet foods, such as candy or cookies, can cause tooth decay. Starchy foods, such as crackers, and sticky foods, such as raisins and other dried fruits, promote tooth decay because they don't dissolve in saliva and collect on the teeth microscopically. But starches and fruits are an essential part of a healthy diet so you shouldn't avoid them. Just give them to your child only at mealtime-not at bedtime-to help reduce the risk of cavities. Avoid letting your child have sugary soft drinks-they are the primary source of sugar in most American children's diets. One can of soda pop contains about 9 teaspoons of sugar. Soft candies-such as licorice or jelly beans-can stick to the teeth and promote tooth decay. Children need to snack to consume enough calories for growth, so stock up on snacks that don't contain a lot of sugar.

Dental checkups and procedures:
Your doctor will check your infant's teeth for any signs of decay during regular checkups. You can begin taking your child to the dentist when he or she is about 3 years old for regular teeth c1eanings, after the primary teeth have come in. From then on, your child should see the dentist twice a year. You may want to ask your doctor to recommend a pediatric dentist, who has 2 to 3 years of additional training in children's dental care, health, and development.

AT THE DENTISTS OFFICE
The major dental problem in children is tooth decay, but some children have abnormalities in their bite or jaw that require correction. Many children have misaligned teeth that will require braces or other orthodontic treatments.

After checking for dental problems, the dentist will instruct you about your child's diet, the use of bottles, and toothbrushing, and will discuss the importance of fluoride. These early dental visits will help your child get accustomed to regular checkups; he or she will come to view visits to the dentist as routine-not scary or painful. Most dentists are sensitive to children's fear as well as their dental care. Try "playing dentist" with your child to make the process more familiar, but avoid using frightening words such as drill, shot, or hurt.

To help diagnose tooth decay or other abnormalities, the dentist may sometimes take X-rays of your child's teeth. The need for X-rays varies from child to child. Children who are susceptible to tooth decay may need to have X-rays at every 6-month checkup; others may need them less frequently. X-rays can detect more than cavities. They can also show erupting teeth, diagnose bone diseases, or evaluate an injury. The dentist will recommend X-rays only after he or she performs a complete examination of your child's teeth and suspects a problem that may not be easily visible.

The equipment used today for dental X-rays minimizes exposure to radiation. To be extra careful, the dentist will place a protective lead apron or shield over your child's neck and torso before taking the X-rays.

Fluoride, a mineral that occurs naturally in many foods and in water, is the most effective agent known to reduce tooth decay. Many municipalities in the United States add fluoride to their water supply, a measure that has greatly reduced tooth decay in both children and adults over the past few decades. The use of fluoride-containing toothpastes has also contributed to a reduction in cavities.

Fluoride provides anticavity protection in a number of ways. It makes teeth harder and more resistant to the corroding effects of acid in the mouth. It can also repair areas of the teeth that have already been damaged, reversing the early decay process. Ask your dentist or doctor if your local drinking water is fluoridated. If not, your dentist may recommend fluoride supplements.

FLUORIDE SUPPLEMENTS Your doctor or dentist may recommend giving daily fluoride supplements to your child in drops, tablets, or lozenges, beginning at about 6 months of age. Your child should take these supplements until age 16 as long as the water supply in your area is not fluoridated. If you move, check with the dentist in your new area to find out if your child needs to continue taking the supplements. A child older than 6 months needs fluoride supplements if breast milk is his or her only source of nourishment. If you are breastfeeding, talk to your doctor.

Follow your dentist's instructions carefully when giving your child fluoride supplements; give only the dose prescribed. Too much fluoride can cause developing teeth to become discolored, a condition called enamel fluorosis. Fluorosis can cause brown marks on the teeth and may make them pitted, rough, and hard to clean. Mild fluorosis causes tiny, barely visible white specks or streaks on the teeth.

FLUORIDE TOOTHPASTES AND MOUTH RINSES Because of the risk of fluorosis, you should not give children fluoride-containing toothpaste or mouth rinse until they can spit it out (usually at about age 2 or 3), or they may swallow too much fluoride. When your children are old enough to use toothpaste and mouth rinse, make sure they don't swallow any. Remember to use only a small, pea-sized amount of fluoride toothpaste on your child's brush.

FLUORIDE TREATMENTS Many dentists recommend topical fluoride treatments for children beginning at about age 3, as part of a child's regular checkups. The dentist or dental hygienist applies concentrated fluoride in a gel or foam to the teeth and keeps it there for 1 minute with a disposable mouth guard. After the guard is removed, the child should not eat or drink anything for 30 minutes to allow the teeth to absorb the fluoride.

Sealants:
The surfaces of the molars have tiny pits and grooves that can trap food particles and bacteria, making the molars especially prone to decay. Many dentists apply a clear, plastic coating called a sealant to the biting surfaces of the permanent molars to prevent decay. It is best to apply a sealant as soon as the permanent molars come in, before they have a chance to decay. The dentist may sometimes recommend sealants on baby molars in young children whose baby teeth are susceptible to cavities.

The procedure for applying a sealant is simple and painless. The dentist "paints" the liquid sealant on the chewing surface of the tooth and then points a light wand at the sealant to harden and attach it to the tooth, forming a protective shield. As long as a sealant remains intact, it is almost 100 percent effective in preventing cavities for up to 5 years. But even if your child has sealants, he or she still needs to see the dentist regularly for checkups and cleanings.
The dentist can examine the sealants for chipping and add any more sealant material, if necessary. Sealants do not protect the areas between the teeth from decay.

TOOTH INJURIES
Baby teeth usually stay in place until the permanent teeth push them out and take their place. Permanent teeth are made to last a lifetime, but falls can injure permanent teeth. Tooth loss can often be avoided if you see a dentist promptly any time your child injures a tooth, even if you don't notice anything unusual. Many injuries in the mouth are easy to see, but some can be hidden beneath the gums.

Injury to a baby tooth from a sharp blow can damage the nerve and cause the tooth to bleed inside and become discolored. Unless a discolored baby tooth develops a serious infection, it is best to leave it in place to maintain the space for the permanent tooth. If the nerve dies in a permanent tooth, the dentist must perform a root canal treatment to save the tooth. A dead nerve left in a permanent tooth will eventually cause an abscess, a pus filled sac that causes severe pain, swelling, and infection. If an abscess develops, a root canal may save the tooth; otherwise, the tooth will need to be extracted.

If your child receives a blow that pushes a permanent tooth up into the gum, take him or her to the dentist right away. The dentist will pull the tooth back down into position. Leave a tooth that is jammed only a short way into the gum; it will gradually return to its normal position. Immediately retrieve a permanent tooth that has been knocked completely out of the socket. Rinse the tooth in cool water (don't use soap), and put it in a clean container with some milk or saliva, which will keep the tooth alive until the dentist can reimplant it. If your child is old enough to follow instructions, he or she can hold the dislodged tooth in its socket with a clean washcloth or piece of gauze until you get to the dentist. (Call the dentist's emergency number if the accident occurs after office hours.) The dentist can then reimplant the tooth and save it. A tooth can be most successfully reimplanted within 30 minutes after it has been knocked out. If your child loses a baby tooth, it will not be reimplanted.

Chipped or extracted teeth Prompt treatment can also save a tooth that is chipped, reducing the risk of infection and the need for extensive dental treatment. Should your child chip a tooth, call your dentist right away. Rinse the child's mouth with water and apply cold compresses to the gum around the tooth to reduce swelling. If you have the chipped piece of tooth, bring it with you to the dentist. Sometimes the dentist can bond the chip back onto the tooth.
If the child is in pain, you can give him or her acetaminophen or ibuprofen.

If your child has a baby tooth extracted early, your dentist may need to insert a metal or plastic device called a space maintainer to prevent the child's adjacent teeth from shifting into the empty space. Without a space maintainer, the permanent teeth could grow in crooked and crowded and eventually require orthodontic treatment. Space maintainers may be temporary or permanent, are custom-made to fit the child's mouth, and are hardly noticeable. Most children adjust to them within a few days.

ORTHODONTIC TREATMENTS
The dentist will routinely look for abnormalities in the position of your child's teeth. If the dentist notices any spacing problems, he or she will refer you to an orthodontist, a dentist who specializes in the treatment of misaligned teeth.

Poor alignment between the upper and lower teeth is known as malocclusion. One type of malocclusion, commonly known as an overbite, occurs when the upper teeth project too far in front of the lower teeth and is often inherited. Orthodontic problems can also result from dental injuries, thumb-sucking, fingernail or lip biting, or overuse of a pacifier.

To diagnose the problem, the orthodontist may take X-rays of the child's head and jaws or make a quick-setting mold of the teeth and gums. This impression enables the orthodontist to study the position of the teeth and structure of the mouth and to design an orthodontic appliance to correct the problem. Some malocclusions are best treated early; at about age 7, while the permanent teeth are coming in and the bones of the jaw are still developing. Early treatment can often forestall more extensive later treatment.

Braces put sustained pressure on the teeth and guide them so they grow into the proper position. Dentists use braces to straighten crooked teeth, guide erupting teeth into position, correct bite problems, and prevent the need for tooth extractions. Some overly crowded teeth may have to be extracted before the braces are put on. Your orthodontist will explain which type of appliance is best for your child, what the treatment can do, and how long it will take.

There are two types of braces-fixed and removable. Fixed braces exert continuous pressure on the teeth and remain in the mouth until the teeth have moved into the correct position. They are fitted to all upper or lower teeth (or both) when many teeth need to be repositioned. Realignment can take a year or longer. Some braces temporarily affect speech, but most children adapt quickly. Fixed braces control tooth movement better than removable braces, but are more expensive and take longer to fit and adjust. They also make cleaning the teeth more difficult.

Removable appliances are used to guide the growth of the upper or lower jaw or for less serious misalignments. There are many types of removable appliances. One type consists of a plastic plate that covers the roof of the mouth and attachments that anchor it over the back teeth. Force is applied to the teeth with springs, wires, screws, or rubber bands fitted to the plate, sometimes combined with headgear. Removable appliances have some disadvantages;
they are bulky and can interfere with speech and the child can remove them so often that they are not effective.

Careful brushing and flossing are essential for keeping the braces and teeth in good condition. Removable appliances should be brushed each time the child brushes his or her teeth.

A child who has braces can continue to eat a normal diet-with the exception of sticky foods (such as gum or caramels) and large, hard foods (such as peanuts, whole apples, ice chips, or unpopped popcorn kernels). Dentists prescribe a daily fluoride rinse for most children undergoing orthodontic therapy.

QUESTIONS PARENTS ASK
Q Is thumb-sucking bad for my daughter's teeth?
A It is normal for children to suck their thumb, fingers, or a pacifier. Most children give up the habit on their own between ages 2 and 4. Thumb-sucking always has the potential to distort the tooth alignment in the upper jaw, but if the child stops the habit before age 5, the chances are usually minimal. If your daughter's thumbsucking concerns you, talk to your dentist and ask for tips about helping her stop the habit, especially if she is still sucking her thumb at age 5.

Q My 4-year-old son grinds his teeth in his sleep. Does he need a mouth guard?
A Grinding of the teeth, known as bruxism, is normal between the ages of 3 and 6 years-when the baby teeth have erupted-so your son does not need a bite guard right now. Most children stop grinding their teeth on their own. If your son continues the habit when his permanent teeth come in, see your dentist, who can decide whether or not to treat the problem.

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