Teething Tots

Teething, the emergence of the first teeth through a baby's gums, can be a frustrating time for little ones and their parents. It helps to know what to expect when your child is teething and how to make the process a little less painful.

The Teething Process

Teething can begin as early as 3 months and continue until a child's third birthday.

Between the ages of 4 and 7 months, you'll notice your baby's first tooth pushing through the gum line. The first teeth to appear usually are the two bottom front teeth, also known as the central incisors. These are usually followed 4 to 8 weeks later by the four front upper teeth (central and lateral incisors). About a month later, the lower lateral incisors (the two teeth flanking the bottom front teeth) will appear.

Next to break through the gum line are the first molars (the back teeth used for grinding food), then finally the eyeteeth (the pointy teeth in the upper jaw). Most kids have all 20 of their primary teeth by their third birthday. (If your child experiences significant delay, speak to your doctor.)

In some rare cases, kids are born with one or two teeth or have a tooth emerge within the first few weeks of life. Unless the teeth interfere with feeding or are loose enough to pose a choking risk, this is usually not a cause for concern.

As kids begin teething, they might drool more and want to chew on things. For some babies, teething is painless. Others may experience brief periods of irritability, and some may seem cranky for weeks, with crying jags and disrupted sleeping and eating patterns. Teething can be uncomfortable, but if your baby seems very irritable, talk to your doctor.

Although tender and swollen gums could cause your baby's temperature to be a little higher than normal, teething doesn't usually cause high fever or diarrhea. If your baby does develop a fever during the teething phase, it's probably due to something else and you should contact your doctor.

Easing Teething

Here are some tips to keep in mind when your baby is teething:

• Wipe your baby's face often with a cloth to remove the drool and prevent rashes from developing.

• Give your baby something to chew on. Make sure it's big enough so that it can't be swallowed and that it can't break into small pieces. A wet washcloth placed in the freezer for 30 minutes makes a handy teething aid — just be sure to wash it after each use. Rubber teething rings are also good, but avoid ones with liquid inside because they may break or leak. If you use a teething ring, be sure to take it out of the freezer before it becomes rock hard — you don't want to bruise those already swollen gums!

• Rub your baby's gums with a clean finger.

• Never tie a teething ring around a baby's neck — it could get caught on something and strangle the baby.
• If your baby seems irritable, acetaminophen may help — but always consult your doctor first. Never place an aspirin against the tooth, and don't rub alcohol on your baby's gums.

Baby Teeth Hygiene

The care and cleaning of your baby's teeth is important for long-term dental health. Even though the first set of teeth will fall out, tooth decay can hasten this process and leave gaps before the permanent teeth are ready to come in. The remaining primary teeth may then crowd together to attempt to fill in the gaps, which may cause the permanent teeth to come in crooked and out of place.

Daily dental care should begin even before your baby's first tooth emerges. Wipe your baby's gums daily with a clean, damp washcloth or gauze, or brush them gently with a soft, infant-sized toothbrush and water (no toothpaste!). As soon as the first tooth appears, brush it with water.

Toothpaste is OK to use once a child is old enough to spit it out — usually around age 3. Choose one with fluoride and use only a pea-sized amount or less in younger kids. Don't let your child swallow the toothpaste or eat it out of the tube because an overdose of fluoride can be harmful to kids.

By the time all your baby's teeth are in, try to brush them at least twice a day and especially after meals. It's also important to get kids used to flossing early on. A good time to start flossing is when two teeth start to touch. Talk to your dentist for advice on flossing those tiny teeth. You can also get toddlers interested in the routine by letting them watch and imitate you as you brush and floss.

Another important tip for preventing tooth decay: Don't let your baby fall asleep with a bottle. The milk or juice can pool in a baby's mouth and cause tooth decay and plaque.

The American Dental Association (ADA) recommends that kids see a dentist by age 1, when six to eight teeth are in place, to spot any potential problems and advise parents about preventive care.

Keeping Your Child's Teeth Healthy

When should I schedule my child's first trip to the dentist? Should my 3-year-old be flossing? How do I know if my child needs braces?

Many parents have a tough time judging how much dental care their kids need. They know they want to prevent cavities, but they don't always know the best way to do so.

When Should Dental Care Start?

Proper dental care begins even before a baby's first tooth appears. Remember that just because you can't see the teeth doesn't mean they aren't there. Teeth actually begin to form in the second trimester of pregnancy. At birth your baby has 20 primary teeth, some of which are fully developed in the jaw.

Running a damp washcloth over your baby's gums following feedings can prevent buildup of damaging bacteria. Once your child has a few teeth showing, you can brush them with a soft child's toothbrush or rub them with gauze at the end of the day.

Even babies can have problems with dental decay when parents do not practice good feeding habits. Putting a baby to sleep with a bottle in his or her mouth may be convenient in the short term — but it can harm the baby's teeth. When the sugars from juice or milk remain on a baby's teeth for hours, they may eat away at the enamel, creating a condition known as bottle mouth. Pocked, pitted, or discolored front teeth are signs of bottle mouth. Severe cases result in cavities and the need to pull all the front teeth until the permanent ones grow in.

Parents and childcare providers should help young kids set specific times for drinking each day because sucking on a bottle throughout the day can be equally damaging to young teeth.

Pediatric Dentists

Consider taking your child to a dentist who specializes in treating kids. Pediatric dentists are trained to handle the wide range of issues associated with kids' dental health. They also know when to refer you to a different type of specialist such as an orthodontist to correct an overbite or an oral surgeon for jaw realignment.

A pediatric dentist's primary goals are prevention (heading off potential problems before they occur) and maintenance (using routine checkups and proper daily care to keep teeth and gums healthy).

Preventing Cavities

The American Dental Association (ADA) recommends that a child's first visit to the dentist take place by the first birthday. At this visit, the dentist will explain proper brushing and flossing techniques (you need to floss once your baby has two teeth that touch) and conduct a modified exam while your baby sits on your lap.

Such visits can help in the early detection of potential problems, and help kids become accustomed to visiting the dentist so they'll have less fear about going as they grow older.

When all primary teeth have come in (usually around age 2½), your dentist may start applying topical fluoride. Fluoride hardens the tooth enamel, helping to ward off the most common childhood oral disease, dental cavities (also called dental caries). Cavities occur when bacteria and food left on the teeth after eating are not brushed away. Acid collects on a tooth, softening its enamel until a hole — or cavity — forms. Regular use of fluoride toughens the enamel, making it more difficult for acid to penetrate.

Although many towns require tap water to be fluoridated, others don't. If the water supply is not fluoridated, or if your family uses purified water, ask your dentist for fluoride supplements. Most toothpastes contain fluoride but toothpaste alone will not fully protect a child's mouth. Be careful, however, since too much fluoride can cause tooth discoloration. Check with your dentist before supplementing.

Discoloration also can occur from prolonged use of antibiotics, and some children's medications that contain a large amount of sugar. Parents should encourage children to brush after they take their medicine, particularly if the prescription will be long-term.

Brushing at least twice a day and routine flossing will help maintain a healthy mouth. Kids as young as age 2 or 3 can begin to use toothpaste when brushing, as long as they're supervised. Kids should not ingest large amounts of toothpaste — a pea-sized amount for toddlers is just right. Parents should always make sure the child spits the toothpaste out instead of swallowing.

As your child's permanent teeth grow in, the dentist can help seal out decay by applying a thin wash of resin to the back teeth, where most chewing occurs. Known as a sealant, this protective coating keeps bacteria from settling in the hard-to-reach crevices of the molars.

Although dental research has resulted in increasingly sophisticated preventative techniques, including fillings and sealants that seep fluoride, a dentist's care is only part of the equation. Follow-up at home plays an equally important role. For example, sealants on the teeth do not mean that a child can eat sweets uncontrollably or slack off on the daily brushing and flossing — parents must work with kids to teach good oral health habits.

If Your Child Has a Problem

If you are prone to tooth decay or gum disease, your kids may be at higher risk as well. Therefore, sometimes even the most diligent brushing and flossing will not prevent a cavity. Be sure to call your dentist if your child complains of tooth pain, which could be a sign of a cavity that needs treatment.

New materials mean pediatric dentists have more filling and repair options than ever. Silver remains the substance of choice for the majority of fillings in permanent teeth.

Other materials, such as composite resins, are gaining popularity. These resins bond to the teeth so the filling won't pop out and can be used to rebuild teeth damaged through injury or conditions such as cleft palate. Tooth-colored resins are also more attractive.

But in cases of fracture, extensive decay, or malformation of baby teeth, dentists often opt for stainless steel crowns. Crowns maintain the tooth while preventing the decay from spreading.

As kids grow older, their bite and the straightness of their teeth can become an issue. Orthodontic treatment begins earlier now than it once did, but what once was a symbol of preteen embarrassment — a mouth filled with metal wires and braces — is a relic of the past. Kids as young as age 7 now sport corrective appliances, and efficient, plastic-based materials have replaced old-fashioned metal. contraptions.

Dentists know that manipulation of teeth at a younger age can be easier and more effective in the long run. Younger children's teeth can be positioned with relatively minor orthodontia, thus preventing major orthodontia later on.

In some rare instances, usually when a more complicated dental procedure is to be performed, a dentist will recommend general anesthesia be used. Parents should make sure that the professional who administers the medicine is a trained anesthesiologist or oral surgeon before agreeing to the procedure.

Don't be afraid to question the dentist. Giving your child an early start on checkups and good dental hygiene is an effective way to help prevent this kind of extensive dental work. Encouraging kids to use a mouthguard during sports also can prevent serious dental injuries.

As kids grow, plan on routine dental checkups anywhere from once every 3 months to once a year, depending on the dentist's recommendations. Limiting intake of sugary foods and regular brushing and flossing all contribute to a child's dental health. Your partnership with the dentist will help ensure teeth healthy and a beautiful smile.

Fluoride and Water

Keeping kids' teeth healthy requires more than just daily brushing. During a routine well-child exam, you may be surprised to find the doctor examining your child's teeth and asking you about your water supply. That's because fluoride, a substance that's found naturally in water, plays an important role in healthy tooth development and cavity prevention.

What Is Fluoride?

Fluoride exists naturally in water sources and is derived from fluorine, the thirteenth most common element in the Earth's crust. It is well known that fluoride helps prevent and even reverse the early stages of tooth decay.

Tooth decay occurs when plaque — that sticky film of bacteria that accumulates on your teeth — breaks down sugars in food. The bacteria produce damaging acids that dissolve the hard enamel surfaces of teeth. If the damage is not stopped or treated, the bacteria can penetrate through the enamel causing tooth decay (also called cavities or caries). Cavities weaken teeth and can lead to pain, tooth loss, or even widespread infection in the most severe cases.

Fluoride combats tooth decay in two ways. It is incorporated into the structure of developing teeth when it is ingested and also works when it comes in contact with the surface of the teeth. Fluoride prevents the acid produced by the bacteria in plaque from dissolving, or demineralizing, tooth enamel, the hard and shiny substance that protects the teeth. Fluoride also allows teeth damaged by acid to repair, or remineralize, themselves. Fluoride cannot repair cavities, but it can reverse low levels of tooth decay and thus prevent new cavities from forming.

Despite the good news about dental health, tooth decay remains one of the most common diseases of childhood. According to the Centers for Disease Control and Prevention (CDC), more than one quarter of 2- to 5-year-olds and half of kids 12 to 15 years old have one or more cavities, and tooth decay has affected two thirds of 16- to 19-year-olds.

Fluoride and the Water Supply

For over 60 years, water fluoridation has proved to be a safe and cost-effective way to reduce dental caries. Today, water fluoridation is estimated to reduce tooth decay by 20-40%. As of 2002, the CDC statistics show that almost 60% of the U.S. population receives fluoridated water through the taps in their homes. Some communities have naturally occurring fluoride in their water; others add it at water-processing plants.

Your child's doctor or dentist may know whether local water supplies contain optimal levels of fluoride, between 0.7 and 1.2 ppm (parts fluoride per million parts of water). If your water comes from a public system, you could also call your local water authority or public health department, or check online at the Environmental Protection Agency's (EPA) database of local water safety reports. If you use well water or water from a private source, fluoride levels should be checked by a laboratory or public health department.

Some parents purchase bottled water for their children to drink instead of tap water. Most bottled waters lack fluoride, but fluoridated bottled water is now available. If fluoride is added, the manufacturer is required to list the amount. If fluoride concentration is greater than 0.6 ppm up to 1.0 ppm, you might see the health claim "Drinking fluoridated water may reduce the risk of tooth decay" on the label.

The Controversy Over Fluoride

Opponents of water fluoridation have questioned its safety and effectiveness; however, there has been little evidence to support these claims.

Scientific research continues to support the benefits of fluoride when it comes to prevention of tooth decay and its safety at current recommended levels of 0.7 to 1.2 ppm. Dramatic reductions in tooth decay in the past 30 years is attributed to fluoridation of the water supply, and parents and health professionals should continue to ensure that kids receive enough fluoride to prevent cavities.

The American Dental Association (ADA), the United States Public Health Service (USPHS), the American Academy of Pediatric (AAP), and the World Health Organization (WHO), among many other national and international organizations, endorse community water fluoridation. The CDC recognized fluoridation of water as one of the 10 greatest public health achievements of the 20th century.

Kids' Fluoride Needs

So how much fluoride do kids need? In general, kids under the age of 6 months do not need fluoride supplements. Your child's 6-month checkup offers a great chance to discuss fluoride supplementation with a health professional. If you live in a nonfluoridated area, your doctor or dentist may prescribe fluoride drops, tablets, or vitamins after your baby is 6 months old.

The AAP recommends that these fluoride supplements be given daily to kids between the ages of 6 months and 16 years. The dosage depends on how much fluoride naturally occurs in the water and the child's age. Only kids living in nonfluoridated areas or those who drink only nonfluoridated bottled water should receive supplements.

What about toothpastes, mouth rinses, and other products that contain fluoride? Here are a few tips:

• Kids under 2 years old should not use fluoride toothpaste unless instructed by a dentist or health professional.

• Kids younger than 6 may swallow too much toothpaste while brushing, so should be supervised when brushing and taught to spit, not swallow, toothpaste.

• Kids over age 2 should use a fluoride-containing toothpaste that carries the ADA's seal of acceptance.

• Kids should use only a pea-sized amount of toothpaste.

• Kids under age 6 should never use fluoride-containing mouth rinses. However, older kids at high risk for tooth decay may benefit from using them. Your dentist can talk with you about risk factors such as a family history of dental disease, recent periodontal surgery or disease, or a physical impediment to brushing regularly and thoroughly.

Your family dentist or pediatric dentist (one who specializes in the care of children's teeth) is a great resource for information about dental care and fluoride needs. A dentist can help you understand more about how fluoride affects the teeth, and once all of your child's primary teeth have come in, may recommend regular topical fluoride during routine dental visits.

Overexposure to Fluoride

If some fluoride is good, why isn't more fluoride better? As with most medications, including vitamins and mineral supplements, too much can be harmful. Most kids get the right amount of fluoride through a combination of fluoridated toothpaste and fluoridated water or supplements.

Too much fluoride before 8 years of age, a time when teeth are developing, can cause enamel fluorosis, a discoloration or mottling of the permanent teeth For most, the changes are subtle. In one study, 94% of identified fluorosis cases were very mild to mild. Most cases are due to inappropriate use of fluoride-containing dental products, including toothpaste and mouth rinses. Sometimes kids take daily fluoride supplements but may be getting adequate fluoride from other sources, which also puts them at risk.

Recently, the National Research Council found naturally occurring fluoride levels exceeded the optimal levels used in community fluoridation programs (0.7 to 1.2 ppm), putting kids under 8 years old at risk for severe enamel fluorosis. The CDC recommends that in communities where fluoride levels are greater than 2 ppm, parents should provide kids with water from other sources.

The ADA also recognizes that infants need less fluoride than older kids and adults. Some infants may be getting too much fluoride in the water used to reconstitute infant formula. If you're concerned that your infant may be getting too much fluoride, talk with your doctor or dentist, who may recommend ready-to-feed formula or formula reconstituted with fluoride-free or low-fluoride water.

Very rarely, fluoride toxicity can occur when large amounts of fluoride are ingested during a short period of time. Kids under age 6 account for more than 80% of reports of suspected overingestion. Although outcomes are generally not serious, fluoride toxicity sends several hundred children to emergency rooms each year.

Symptoms of fluoride toxicity may include nausea, diarrhea, vomiting, abdominal pain, increased salivation, or increased thirst. Symptoms begin 30 minutes after ingestion and can last up to 24 hours. If you suspect your child may have eaten a substantial amount of a fluoridated product or supplement, call the poison control center or 911.

Be sure to keep toothpaste, supplements, mouth rinses, and other fluoride-containing products out of children's reach or in a locked cabinet. You should also supervise your young child's toothbrushing sessions to prevent swallowing of toothpaste or other fluoridated products.

If you have any questions about your water's fluoride content, the fluoridated products your child uses, or whether your child is receiving too much or too little fluoride, talk to your doctor or dentist.

Bruxism (Teeth Grinding or Clenching)

When you look in on your sleeping child, you want to hear the sounds of sweet dreams: easy breathing and perhaps an occasional sigh. But some parents hear the harsher sounds of gnashing and grinding teeth, called bruxism, which is common in kids.

About Bruxism

Bruxism is the medical term for the grinding of teeth or the clenching of jaws. Bruxism often occurs during deep sleep or while under stress. Two to three out of every 10 kids will grind or clench, experts say, but most outgrow it.

Causes of Bruxism

Though studies have been done, no one knows why bruxism happens. But in some cases, kids may grind because the top and bottom teeth aren't aligned properly. Others do it as a response to pain, such as an earache or teething. Kids might grind their teeth as a way to ease the pain, just as they might rub a sore muscle. Many kids outgrow these fairly common causes for grinding.

Stress — usually nervous tension or anger — is another cause. For instance, a child might worry about a test at school or a change in routine (a new sibling or a new teacher). Even arguing with parents and siblings can cause enough stress to prompt teeth grinding or jaw clenching.

Some kids who are hyperactive also experience bruxism. And sometimes kids with other medical conditions (such as cerebral palsy) or on certain medications can develop bruxism.

Effects of Bruxism

Many cases of bruxism go undetected with no adverse effects, while others cause headaches or earaches. Usually, though, it's more bothersome to other family members because of the grinding sound.

In some circumstances, nighttime grinding and clenching can wear down tooth enamel, chip teeth, increase temperature sensitivity, and cause severe facial pain and jaw problems, such as temporomandibular joint disease (TMJ). Most kids who grind, however, do not have TMJ problems unless their grinding and clenching is chronic.

Diagnosing Bruxism

Lots of kids who grind their teeth aren't even aware of it, so it's often siblings or parents who identify the problem.

Some signs to watch for:

• grinding noises when your child is sleeping
• complaints of a sore jaw or face in the morning
• pain with chewing

If you think your child is grinding his or her teeth, visit the dentist, who will examine the teeth for chipped enamel and unusual wear and tear, and spray air and water on the teeth to check for unusual sensitivity.

If damage is detected, the dentist may ask your child a few questions, such as:

• How do you feel before bed?
• Are you worried about anything at home or school?
• Are you angry with someone?
• What do you do before bed?

The exam will help the dentist determine whether the grinding is caused by anatomical (misaligned teeth) or psychological (stress) factors and come up with an effective treatment plan.

Treating Bruxism

Most kids outgrow bruxism, but a combination of parental observation and dental visits can help keep the problem in check until they do.

In cases where the grinding and clenching make a child's face and jaw sore or damage the teeth, dentists may prescribe a special night guard. Molded to a child's teeth, the night guard is similar to the protective mouthpieces worn by football players. Though a mouthpiece may take some getting used to, positive results happen quickly.

Helping Kids With Bruxism

Whether the cause is physical or psychological, kids might be able to control bruxism by relaxing before bedtime — for example, by taking a warm bath or shower, listening to a few minutes of soothing music, or reading a book.

For bruxism that's caused by stress, ask about what's upsetting your child and find a way to help. For example, a kid who is worried about being away from home for a first camping trip might need reassurance that mom or dad will be nearby if anything happens.

If the issue is more complicated, such as moving to a new town, discuss your child's concerns and try to ease any fears. If you're concerned, talk to your doctor.

In rare cases, basic stress relievers aren't enough to stop bruxism. If your child has trouble sleeping or is acting differently than usual, your dentist or doctor may suggest further evaluation. This can help determine the cause of the stress and an appropriate course of treatment.

How Long Does Bruxism Last?

Childhood bruxism is usually outgrown by adolescence. Most kids stop grinding when they lose their baby teeth. However, a few kids do continue to grind into adolescence. And if the bruxism is caused by stress, it will continue until the stress is relieved.

Preventing Bruxism

Because some bruxism is a child's natural reaction to growth and development, most cases can't be prevented. Stress-induced bruxism can be avoided, however, by talking with kids regularly about their feelings and helping them deal with stress. Take your child for routine dental visits to find and, if needed, treat bruxism.