In this special focus on children’s oral health, we asked a couple of tooth fairies for some best-practice advice.
After weeks of grossing everyone out with incessant tooth wiggling, those two front teeth eventually came out. But they’re not all my seven-year-old granddaughter Mia (pictured) wants for Christmas this year. Also on her wish list are: (1) a Fitbit (go for a run around the garden, says her mum), (2) a pet guinea pig (not happening, says her dad), and (3) a live chicken – in a household ruled by two dogs and a cat!
Apart from its amusement value, this list serves as a reminder of why we adults are still mostly in charge. But being the decision-maker is not always easy, especially when it comes to your children’s health.
It can be a minefield. Not only are new discoveries being made every day, but previously immutable truths are falling like ninepins – making it really difficult to keep up with the latest thinking and to make what you can only hope are the right choices.
Oral health is not something separate from general health. Instead, it’s integral to overall wellbeing, and a healthy mouth helps a growing child to develop good speech, balanced eating habits, effective social skills and more.
Those first baby teeth are important little milestones, as are those initial “big teeth” making their way through Mia’s upper gums. Fortunately, they’re external and therefore highly visible markers – accessible for regular brushing, flossing and dental check-ups.
Language acquisition is another area that may seem fairly easy to monitor. But children learn to speak at their own pace – girls generally more quickly than boys – and it’s not always that simple. The three-year-old son of friends of ours has only just been diagnosed as almost completely deaf; just imagine how his parents feel.
In the end, it takes a specialist to diagnose a problem and come up with a solution – and sooner is generally better than later.
Healthy Baby Teeth
DR STEPHANIE SALANITRI of Smilefocus has a special interest in paediatric dentistry. For her, treating children is extremely rewarding – it means setting them up for a healthy, beautiful smile that will last a lifetime.
She stresses the importance of avoiding early childhood caries (ECC). ECC is defined as the presence of one or more decayed, missing or filled surfaces in any primary tooth in a child who’s not yet turned six.
Baby teeth are especially vulnerable to decay, she explains. This is because the enamel is softer and thinner than the enamel of adult teeth. “So when sugar or food acids come into contact with the teeth for long periods, or too frequently, they can start causing damage. Even fruit juice and fresh fruit have a high sugar content.”
The softness of the baby teeth means that decay can spread very rapidly, sometimes even in just a few months. “That’s why it’s important to take radiographs to see if there are any areas of decay between the teeth as well as on the visible surfaces. A different radiograph, called an OPG, will show the development of the adult teeth and assist in determining current treatment, and possible future treatment as the child matures.”
The Main Culprit
The main known cause of caries or decay is Mutans streptococci (MS), says Dr Salanitri. “At birth, a new-born’s mouth is sterile. One of the key risk factors for ECC is the transfer of MS bacteria from the mother or caregiver’s saliva to the baby.”
There is a much bigger chance of this happening when the mother or caregiver has high levels of MS, says the doctor; the critical age is approximately seven months, just before the teeth begin to erupt.
Avoid kissing your baby on the mouth, seems to be the first message – and discourage others from doing so either. It’s also vitally important that all caregivers be dentally healthy, free from dental decay or gum disease, because caregivers who have good oral health are less likely to pass on the MS bacteria to the child. “That goes for everyone who interacts with babies,” she adds, “including fathers, older siblings, extended family, nannies and day-care staff.”
The Fluoride Debate “Fluoride works to prevent the bacteria present in plaque from dissolving tooth enamel”
If you’ve been wondering about fluoridated toothpaste, you’re not alone. The current fluoride debate has been going on for decades – both with regard to the addition of fluoride to public drinking water (a controversial and by no means universal practice) and the topical use of fluoride, especially as an ingredient of toothpaste.
Like most dental practitioners I’ve spoken to, Dr Salanitri is strongly in favour of fluoridation, both in our water supply and in toothpaste. Fluoride works in two ways, she says: “Firstly, on the un-erupted developing adult teeth in your child; and secondly, on the teeth that have already erupted into the mouth. Evidence has shown that the contact of fluoride with the tooth is the most important preventive measure against tooth decay.”
A child’s adult teeth start to form at birth, she explains, and fluoride helps in the formation of strong healthy teeth. Incorporated into the structure of developing teeth, it works towards preventing the bacteria present in plaque from dissolving tooth enamel. “In Singapore the water is fluoridated*, and in combination with fluoride toothpastes is a good source of fluoride for children.”
She sounds a note of caution, however. “Before your child starts to brush with fluoride toothpaste, be sure that he or she is able to spit properly.” That’s because ingesting excess fluoride can cause discolouration or fluorosis of the adult teeth during development. “The crowns of the adult teeth are especially vulnerable while they’re being formed, which occurs during the first three years of life.”
Less than a pea-sized amount of fluoridated toothpaste is all you need. “If your child is more susceptible to decay, however, your dentist or hygienist may suggest additional applications of topical fluoride.” * Current levels of fluoridation in Singapore’s drinking water are reportedly 0.4 to 0.6mg per litre, generally considered to be the optimal level.
A Stitch in Time
Time for your child’s first orthodontic checkup? This is one decision that’s been made for you: according to the American Association of Orthodontists, every child should be assessed by no later than the age of seven, as orthodontist DR CATHERINE LEE reminds us.
The first permanent molars and incisors have usually come in by then, allowing the orthodontist to detect and evaluate any problems, advise whether treatment will be necessary, and determine the best time for treatment.
Early treatment is all about working in a complementary way with the child’s growth. For example, says Dr Lee, a common orthodontic problem is when the upper front teeth protrude ahead of the lower ones, often due to the lower jaw being shorter than the upper jaw. “While the upper and lower jaws are still growing, orthodontic appliances can be used to help the growth of the lower jaw catch up to that of the upper jaw.”
At this stage, even severe jaw length discrepancy can be treated quite effectively in this way. “However, if the problem is left untreated until the jaws have stopped growing, the child might require corrective surgery. Children who may have problems with the width or length of their jaws should be evaluated for treatment no later than age 10 for girls and age 12 for boys.”
In her role as Singapore spokesperson for Invisalign – known for its “invisible braces” technology – Dr Lee is working with that company on a new feature developed to treat children during their growing phase, and particularly to help correct any issues arising from jaw growth imbalance. Excitingly, she says, it’s due to be launched in the new year.
Thumb-sucking can affect your child’s bite, says Dr Lee. “In a normal bite, the upper teeth grow to overlap the lower teeth. But the pressure of a thumb, finger or pacifier resting on the gums can interfere with normal tooth eruption and even jaw growth.” This can lead to speech development problems, or to protruding front teeth.
Loss of a baby molar could be problematic, because one of the functions of baby molar teeth is to reserve the spaces needed for the permanent teeth. “When a baby molar tooth is lost prematurely,” she explains, “we can put in place a space-maintainer – a fixed-wire device – to keep that space open until the permanent tooth starts to emerge.”
Phase I, or early interceptive treatment, is done before all the permanent teeth have erupted, usually between the ages of 6 and 10.
Phase II treatment, involving braces, begins around age 12 when all primary teeth have been lost and the second adult molars appear.
Severe crowding may call for the pulling of one or more baby teeth, so as to allow the bigger adult teeth to emerge in time. “Otherwise, some of the new teeth (usually the canines) could remain impacted – stuck in bone and unable to come into the mouth – or emerge in a highly undesirable position.”
Serial extraction of baby teeth and new permanent teeth allows crowded teeth to move naturally into better positions and can dramatically relieve the problem. Usually, this would be done just before Phase II orthodontic treatment.
“Don’t delay bringing your child in for specialist assessment,” urges Dr Lee. “Early orthodontic intervention could help avoid much future misery for your child, not to mention the expense to you.”
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