Dental care for babies and young children

• Effective chewing of food. Missing or decayed baby teeth will cause children to reject foods that are difficult to chew or cause pain;
• Maintaining normal appearance. Children with missing or decayed teeth can become self-conscious and withdrawn. They can also be a target for teasing and bullying from other children;
• Developing clear speech patterns. Missing or decayed baby teeth can lead to speech problems that can be difficult to correct;
• Proper jaw development, and;
• Maintaining space for and guiding the eruption of the permanent teeth. Missing baby teeth can cause the permanent teeth to erupt in the wrong place, or be very crowded and require corrective orthodontic treatment at a later age.

Tooth development in babies and children

Baby teeth

Baby teeth start to form in the jawbone before birth. A baby's first tooth usually appears at around six months of age, but can be as late as 12 months, or soon after birth. Some babies are born with one or more baby teeth already present. This is unusual, although not harmful unless the tooth is very loose and at risk of falling out and being inhaled or swallowed.

Baby teeth continue to appear in the mouth (erupt) until the child has a full set of 20 baby teeth by the time they are three years old.

Teething

Teething refers to the appearance in the mouth, or the eruption, of the baby teeth. Many babies and children feel discomfort as their first tooth erupts at around six months and when their other baby teeth erupt. When teething, babies and children may be irritable and have difficulty sleeping and feeding. Signs and symptoms of teething include:

• Frequent crying and irritability;
• A tendency to chew on objects and fingers;
• Dribbling may increase and the cheeks redden;
• A rash may develop on the face or buttocks;
• Gums can be swollen and red;
• A slight fever may develop, and;
• Loss of appetite.

Temporary relief from the discomfort of teething may be provided in the form of a cold teething ring or toy, cooled in the fridge and not in the freezer. A range of teething gels are available to soothe the gums when teething. Always consult your doctor or pharmacist before using teething gels that contain anesthetic, or before giving your child pain medication. Always follow the instructions on the label and consult your doctor if in doubt. Never give a baby or child aspirin.

Permanent teeth

Permanent teeth (also called adult teeth) begin to appear in the mouth at about six years of age. The lower front teeth and the first permanent molars are the first to erupt. Permanent teeth appear in the space in the gum after the baby teeth have fallen out. The baby teeth will become loose one by one and fall out, usually painlessly, although some bleeding can occur.

Children can have difficulty chewing and brushing their teeth when they have loose baby teeth. Offer them soft, healthy foods and take care when brushing loose baby teeth.

Occasionally a permanent tooth will erupt before the baby tooth has fallen out. If the baby tooth is loose, it will often fall out in the days or weeks following. If it is not loose and has not been lost after two to three months, consult your dentist.

Permanent teeth are usually not as white as the baby teeth. This is normal and as the tooth enamel matures on the permanent teeth, it often becomes lighter in color. Permanent front teeth usually have small bumps on the edges when they first erupt. This is a normal appearance and these bumps usually wear down as the teeth come into contact with other teeth and start to function.

While most children look forward to losing their baby teeth and are excited about getting permanent teeth, some children can be anxious about loose teeth. Celebrate lost baby teeth with your child. Reassure them that this is a normal part of growing up.

Children will continue to lose baby teeth and grow new adult teeth usually until around 12 years of age. If you are concerned about the rate at which your child is developing new teeth, speak with your dentist. Generally, if a child is late to develop their baby teeth, the permanent teeth may also be late to erupt.

Caring for baby teeth

It is recommended that you clean your baby's teeth daily, as soon as they appear in the mouth. This is normally at around six months of age. A soft washcloth can be used to wipe the teeth and gums, particularly after feeding at this age. A soft-bristled small toothbrush can be introduced to clean a baby's teeth using only water at around six to 12 months. Up to the age of 18 months, you need to brush a child's teeth with only plain water, but at least twice a day.

Special low-fluoride toothpastes are available for children from the ages of 18-24 months. It is important that only a small amount of toothpaste is used and that the child spits the paste out after brushing and does not swallow it. Check with your pediatrician or dentist if the water in your area is fluoridated. Fluoride toothpastes may be introduced earlier upon recommendation from your dentist or pediatrician if the town water is unfluoridated, or if there is a high risk of tooth decay.

While fluoride is extremely effective in reducing tooth decay in children and adults, it can be dangerous if recommended doses are exceeded. Keep all fluoride-containing products (e.g. toothpastes, gels, mouthwashes) out of the reach of children. Some children like the taste of toothpaste and will eat it from the tube if given the chance. Swallowing or drinking fluoride-containing products can poison small children, or result in fluorosis of their permanent teeth.

Parents are advised to help young children to brush their teeth thoroughly at least twice a day. It is useful to allow the child to try brushing their own teeth first. Most children lack the fine motor skills to effectively brush their own teeth until at least six or seven years of age. Even at this age, it is important that an adult supervises the cleaning and inspects the child's mouth afterwards.

Dental floss is used to clean in-between the teeth to remove food and plaque that the toothbrush cannot reach. Dental floss can be introduced at around the age of three, or when all the baby teeth are present. Food can easily become trapped between teeth and cause tooth decay in baby teeth as well as adult teeth. Hold the floss tightly and gently push it between the teeth and back up again, taking care not to cut into the gums.

Regular tooth brushing helps prevent tooth decay. 

Baby's first dental visit

It is advised to begin visits to the dentist within six months of the first tooth appearing and before 12 months of age. Early detection and prevention of dental problems is the goal. Your dentist will be able to offer advice on good oral health for your child.

For many children, the first dental visit is focused on familiarizing your child with the dental setting and helping them accept that dental visits are part of normal life. The following suggestions will help your child have a positive experience at their first dental visit:

• It is useful to take your child with you when you have your dental check-up. This way, your child will become familiar with the surroundings and staff at the dental office;
• Older siblings are helpful in modelling behavior. Take your child along to the dentist with older siblings, or other older children who are familiar and at ease with dental visits;
• Make your child's appointment earlier in the day when your child is not tired;
• Talk to your child about the visit in a positive way. Explain that the dentist will give them a ride in the chair and count their teeth;
• Some children feel more comfortable sitting on a parent's lap in the dental chair;
• Avoid using language about the dentist that may alarm your child, such as telling them to "try to be brave" or "it won't hurt", and;
• Try to passively observe the dental staff with your child and allow them to engage your child's attention.

Your child may not cooperate at their first visit. It may take a few visits before your child is comfortable enough to allow a proper dental examination. Your dentist will advise you on how to encourage cooperation from your child and what to do at home to maintain good oral health. It is important to be encouraging of your child, not to threaten your child or frighten them about what will happen at the dentist if they do not cooperate.

Dental conditions in babies and children

Tooth decay

Tooth decay can occur in baby teeth and can lead to toothache, pain, infection and early loss of teeth. Early childhood caries can occur in children as young as six to 12 months. It usually appears around the fronts of the upper-front baby teeth, which develop a dull white band along the gum line. This progresses to brown patches, then cavities that encircle the tooth at the gum line.

In advanced cases, the crowns of the teeth may be destroyed completely, leaving decayed, brown-black stumps. Treatment in the early stages may consist of trying to re-mineralize the damaged tooth surface and eliminate the cause of the decay. Changing feeding practices and introducing better oral hygiene can help prevent the progress of the tooth decay. In advanced cases of early childhood caries, treatment may be difficult for very young children who are not capable of undergoing lengthy dental treatment. Often a general anesthetic in hospital is needed to properly restore the child's teeth.

Early childhood caries can be prevented by following these guidelines:

• Never put anything into a baby's bottle other than milk, infant formula or plain water;
• Avoid putting a baby to bed with a bottle, or breastfeeding the baby to sleep. This allows the milk to pool around the teeth when the baby is sleeping and can cause tooth decay;
• Do not dip a dummy in any liquid or food before giving it to the baby;
• Introduce foods that are low in sugar, unprocessed and natural. Do not sweeten baby food;
• Keep your own mouth healthy and free from disease. Bacteria from parents' and carers' mouths are easily passed on to babies. This can then increase the risk of tooth decay for the child. Avoid using the same spoon to taste baby's food, or putting the baby's dummy or bottle in your mouth, and;
• Children's medicines are often in syrup form and can contain high levels of sugar. Ask your pharmacist for a sugar-free variety of medicine when needed. If this is not available, make sure you brush your child's teeth after giving the medicine.

Thumb sucking

Babies have a strong sucking reflex, which can extend to non-nutritional sucking of fingers, thumbs, dummies and other objects. This is a normal activity and often provides comfort to the baby. This can become problematic, however, if it is continued beyond the age of two or three years. The constant pressure on the growing teeth and jaws will cause malformations over time. The upper jaw typically becomes narrow and protruded with the upper teeth being pushed forward. An open-bite can also develop, where the child can no longer bring the edges of their front teeth together to bite into food. Difficulties with eating and proper speech are common.

The effects of non-nutritional sucking on the developing mouth are usually reversible up until the age of four or five years. This is when the permanent teeth start to erupt into the mouth. Any continued thumb or finger sucking beyond this age is likely to require orthodontic treatment to correct the deformations caused by the sucking habit. Protruding front teeth, a distorted bite and poorly-aligned jaws are often the result.

It is interesting to note that children who suck their thumb or fingers have a greater problem in breaking their habit than children who suck a dummy. For this reason, try to encourage your child to stop their sucking habit at around two or three years of age. It can take some time to wean a child off this habit completely and a number of different strategies, together with a good dose of patience, may be needed. Your dentist can offer advice on breaking your child's sucking habit.

Tips for breaking your child's thumb-sucking habit include:

• Explain to the child that you would like them to stop the habit and why this is important;
• Reward the child with a hug or praise when you notice they are not sucking their thumb or finger;
• Use a calendar or wall chart with stickers or stars placed for every period of time the child resists their sucking habit. A certain number of stickers or stars may then be rewarded with a special outing, a toy or a privilege;
• Offer encouragement during difficult times. Children may revert to sucking when tired, stressed or hungry. It may take several attempts and many months before the habit has been successfully broken;
• Limit nagging or threatening the child, as this will increase stress and make breaking the habit more difficult, and;
• Children who persist in a sucking habit beyond four years of age may need additional help with breaking the habit. Consult your dentist or orthodontist for advice. In older children, a dental appliance can be fitted in the mouth to prevent thumb sucking when other methods have been unsuccessful. There are various thumb guards available that can be worn to make thumb sucking unpleasant.

Injuries to baby teeth

Toddlers and young children often experience falls as they are learning to walk and explore their environment. Sometimes these falls and accidents can involve an injury to the teeth.

In the case of a chipped or broken baby tooth, the advice of a dental professional should be sought as soon as possible. Where the chip is very small, it may need only to be smoothed of any rough edges, provided that the tooth is not sensitive. If the tooth has broken and exposed the pulp (nerve and blood vessels) inside the tooth, it will be very painful for the child and will require more complex treatment.

If a baby tooth is knocked out of the mouth, do not place it back in the socket. This can damage the erupting permanent tooth and cause problems with normal development. Seek dental advice as soon as possible and take any tooth fragments with you to the dental professional.

Injuries to permanent teeth

If a permanent tooth is chipped or broken, seek dental treatment as soon as possible. Take any broken tooth fragments with you. These can sometimes be bonded back into place if they are in one piece.

If a permanent tooth is knocked out, replace it in the socket as soon as possible. The longer the tooth is out of the socket, the smaller the chance that it will survive. Every minute is important. Seek dental advice immediately.

Follow these steps for a knocked-out permanent tooth:

• Find the tooth;
• Hold the tooth by the crown only, not by the root;
• If the tooth has debris on it (i.e., if it has fallen on the ground), gently rinse it in milk or saline solution for a few seconds;
• Do not scrub the tooth or use cleaning agents;
• Do not let the tooth become dry;
• Replace the tooth immediately if the child is conscious. Take care to put it in the right way. Look at the other teeth to guide you. Hold the tooth in place by gently biting on a handkerchief, and then;
• Contact a dental professional immediately.

If you cannot replace a permanent tooth in its socket:

• Store the tooth in milk or saline solution and seek immediate dental treatment, or;
• If milk or saline is unavailable, wrap the tooth in plastic so it does not dry out. If plastic wrap is unavailable, store it in the child's cheek, only if the child is conscious and calm. Take care that it is not swallowed or breathed into the lungs and seek immediate dental treatment.

Preventing tooth decay with fissure sealants

Fissures are the grooves that naturally occur on the biting surfaces of the teeth. It is well known that the majority of tooth decay occurs in these fissures. All molars and premolars have fissures to some extent.

If the fissures are very deep and narrow, food and plaque will collect in them and cause tooth decay. Toothbrush bristles often cannot reach into the fissures to clean them. Fissures are five times more likely to develop tooth decay than any other surface of the tooth.

For this reason, fissure sealants have been developed to seal the grooves in the teeth and prevent food and plaque collecting and causing tooth decay. Fissure sealants are very effective in protecting teeth from decay. For effective protection, you can have them applied to your child's permanent molar tooth as soon as it erupts into the mouth. The first molar teeth erupt into the mouth at around six years of age. A dental visit can be scheduled at this stage to check your child's teeth and determine if fissure sealants are needed. Other permanent teeth such as premolar teeth and the second molars will erupt later and can also be sealed. Some incisor teeth and canine teeth have pits or grooves in the enamel, which can collect plaque and food and also be difficult to clean. Your dentist may suggest fissure sealants be applied to these teeth as well to prevent decay.

Applying the fissure sealants is painless and non-invasive. After cleaning the tooth and removing any debris from the fissures, a coat of liquid sealant is applied to the fissures. The liquid sets in minutes and bonds to the tooth, forming a barrier that stops food, plaque and acids from contacting the grooves of the tooth. Fissure sealants may be white in color, clear or tinted.

Fissure sealants wear down over time and can chip and fall off after many years of use. They should be regularly inspected and reapplied if needed. As no drilling of the tooth is needed to apply a fissure sealant, the tooth does not suffer any damage when a sealant wears down or falls off.

Fissure sealants can also be applied to baby teeth if they appear at high risk of tooth decay. Adults can also have fissure sealants to preserve their healthy adult teeth.

Sealed teeth do not require any special home treatment or dietary changes. Although the fissure sealant protects the biting surface of the treated tooth from decay, other surfaces of the tooth can still become decayed. It is important to regularly brush and floss the teeth to prevent tooth decay.

Healthy eating for healthy teeth

For infants

Breastfeeding is the preferred method of infant feeding as recommended by the World Health Organization (WHO) until the child is 12 months of age, or longer if desired. If breastfeeding is not possible or supplementary feeding is necessary with additional foods or fluids, the following recommendations are useful:

• Only put milk, infant formula or water in a baby's bottle. Never give a child a bottle filled with juice, soft drink, cordial or anything else;
• Never put a baby to bed with a bottle. Remove the bottle when the baby has finished feeding, and;
• Introduce a feeding cup at around six to eight months of age. A bottle is not needed for healthy children over the age of 12 months.

For toddlers and older children

Solid foods can be introduced at around 4-6 months of age. Seek advice from your pediatrician. Nutritious, healthy foods are important for normal development and growth. It is also important to develop good eating habits at this age and allow the child to develop a taste for the right foods.

Children often need frequent small-sized meals. Offer healthy foods for meals and snacks.

Encourage your child to drink water when they are thirsty. Water is a much better thirst-quencher than fruit juice or sweetened drinks. Many juices and soft drinks are acidic and damaging to the teeth. They also tend to fill up the stomach and reduce the child's appetite for nutritious food.

Examples of foods to encourage include:

• Fruit (fresh or stewed);
• Vegetables (fresh, raw, steamed or cooked);
• Grains and cereals with no added sugar;
• Dairy foods such as milk, cheese or yoghurt, and;
• Meat or protein-rich foods, e.g., lean meats, beans, eggs, tofu and lentils.

A selection of foods for healthy teeth. 

Examples of foods to limit or avoid:

• Sweetened breakfast cereals;
• Fruit bars and muesli bars;
• Cake;
• Sweet biscuits;
• Chocolate and candy;
• Sweet spreads, e.g. jam and honey, and;
• Ice-cream or desserts.

Frequent consumption of these sweet, sticky foods can contribute to tooth decay. It is best to limit how often your child eats these foods. Aim to have your child eat these at mealtimes rather than as snacks. Saliva flow is greatest at mealtimes and helps to wash away sweet foods and neutralize the acids produced by bacteria that are damaging to teeth. Frequent snacking on sweet, sticky foods in-between meals increases the damage to the teeth.