Dentists gone wild! Cavities in baby teeth may not need fillings

The Pediatric Insider

© 2016 Roy Benaroch, MD

Clara wrote in:

“My six year old has being seeing a dentist for three years, and has never had any problems. At the last visit, his dentist identified three cavities on x-rays, and recommends capping the teeth with stainless steel caps. He’s not having any pain or problems. This seems like a lot of expense and a big deal for baby teeth. Is the dentist just trying to make more money?”

Well, I’m not a dentist, and I haven’t examined your child. But the story does sound fishy to me.

Some background: dental cavities (or “caries”) have become much less common in the developed world, from both improved hygiene and the widespread use of water fluoridation. Not only are cavities relatively rare, but small cavities can often reverse themselves, or at least stay small, with good oral hygiene. It wasn’t like that before fluoridation. Until the 1970’s, once a cavity started, it was going to get bigger and worse. Dentists had to be more aggressive back then.

There are some groups of children who are still at risk for extensive dental disease, and those kids really need more-aggressive care. These include children with poor oral habits (like sleeping with a bottle of milk or a sippy cup of juice), or children with serious developmental challenges that make good hygiene and exams difficult. Some of these kids may have a hard time communicating that their teeth hurt, so we need to be extra careful. Severe crowding or other oral health problems can also contribute to extensive tooth decay.

But most of our children have very few (if any) cavities, and the ones they do get remain small and don’t cause any problems. Small cavities can be safely monitored at dental visits, to make sure they don’t get worse. They don’t need to be filled, and the teeth that get them don’t need to be capped. Junior does need to make sure that she’s brushing well and staying away from soda and sticky candy.

Cavities that are more likely to need fillings or caps are those that continue to grow, especially if they erode near the center of the tooth. Pain or temperature sensitivity can be signs of a significant cavity or other oral problem that needs dental attention. Sometimes, cavities form in a way that weakens the tooth, or might allow decay to spread to other teeth. A dentist can help decide which cavities are the ones to worry about.

I suggest Clara (or any other parent who’s concerned about overly-aggressive recommendations for dental care in baby teeth) seek a second opinion from a qualified, experienced pediatric dentist. Most cavities in baby teeth don’t need intervention, but some do, and you need a good dentist to help figure that out.

Disclaimer: I’m not a dentist, I did write a chapter in a pediatric textbook on dental health, so I’m reasonably tooth-savvy. I also called my kids’ own pediatric dentist this morning to make sure I was giving reasonable advice here. Thanks Dr. Mac, you da best!

Start using fluoride-containing toothpaste as soon as baby teeth come in

The Pediatric Insider

© 2014 Roy Benaroch, MD

A new guideline from the American Dental Association suggests that parents start using fluoride toothpaste early to best protect teeth. (The guideline itself is behind a paywall, but you can read a summary here.)

The old advice was to wait until age two to use fluoride. The concern had been that babies can’t spit well (ironic—they seem to spit up just fine when they want to), and that early fluoride could lead to fluorosis, or a staining of teeth. But it turns out that the vast majority of children with fluorosis have minimal cosmetic changes that are only noticeable by a dental professional, and that mild fluorosis actually strengthens teeth. An appropriate amount of fluoride toothpaste, when used very young, will lead to fewer cavities and better dental health.

How much is the right amount? The ADA is suggesting just a smear, or a bit of toothpaste about the size of a single grain of rice. That’s not a lot. Even for older kids, past three, a pea-sized amount is plenty. (That’s what’s recommended for adults, too. The big blobby stripe of toothpaste shown in commercials is there just to trick you into using too much.)

Once teeth come in, brush them twice a day with a rice-sized bit of fluoride-containing toothpaste twice a day. Now, if we could also get them to floss….

Who needs a pediatric dentist? And when?

The Pediatric Insider

© 2013 Roy Benaroch, MD

Tanya asked, “Should I take my kids to a pediatric dentist?”

Maybe, maybe not. Children do need a dentist who’s sensitive and good with children—but that doesn’t necessarily mean it has to be a pediatric-only dentist (or “pediadontist”.) Many family dentists do a great job with everyone. I think it’s fine if parents take their kids to their own dentists, as long as the dentist is comfortable and good with children.

How can you tell? Ask. I think most dentists who prefer not to see children will tell you that, right up front. If your dentist says, “Well, we rarely see kids here” that tells you something. You should also look around the office and waiting room. If there are no kid-friendly toys or murals about, chances are children rarely go there. Do all the magazines feature Oprah, or are there little short chairs next to a sand table? Subtle clues abound.

There are some dental procedures that require specific child techniques or anesthesia, best done in a child-only practice. Your own dentist will refer you to a ped-dentist if that’s what you need. If you’re ever uncomfortable about anesthesia in an adult office, ask your dentist how often they do that. Or get a second opinion from a pediadontist.

According to the American Dental Association (ADA), children should have a dental home by age one. I’m not sure that’s always necessary or practical. The ped dentists near me recommend seeing children for a first visit at age 3 – 3 ½.

Whenever you decide to see a dentist, follow these tips to keep teeth clean and healthy starting young:

• Never put a baby to bed or nap with a bottle.
• Start brushing at age 1 with a soft brush and a tiny, rice-sized dab of fluoride-containing toothpaste.
• Stop using baby bottles by 12 months of age—especially the one that leaves baby’s mouth full of milk at bedtime. After a last snack, brush teeth before bed.
• Once complementary foods are added, babies should also drink water with meals. Water—not juice, not anything sweetened. Water. Ordinary, cheap, fluoridated tap water. Mmmmm.
• Avoid sugary drinks, including juice, which is about as nutritious as soda.
• Don’t let your child stroll around all day with a sippy cup.

If you haven’t been able to follow those steps, or have a strong family history of teeth problems, or you or your child’s doctor see problems with your child’s teeth, you ought to head to the dentist early—by age 1, as the ADA recommends. Whether it’s a ped-only or a general, family dentist is probably less important than overall good nutrition and dental habits.