As soon as teeth are present, dental care should be discussed at every pediatric well-child visit. Many parents do not ask their pediatricians about dental care, assuming that it is the dentists' domain, but some families do ask lots of questions. Either way, pediatricians should discuss dental care at well visits, answering any questions and offering anticipatory guidance, especially on how to prevent caries. There are many questions from parents about dental care: how to brush, what kind of toothpaste to use, how to stop their child from grinding his or her teeth, whether or not pacifiers are bad for tooth development, and other inquiries that are addressed in the article. This article acts as a quick reference guide for pediatricians, so they are prepared to answer common questions about oral health. [Pediatr Ann. 2016;45(11):e379–e381.]
There are many questions that pediatricians are asked on topics that are not necessarily medical problems—how to sleep train, how to discipline, and how to find a nanny. Another topic that parents commonly ask about is dental care. This article goes over common questions that parents may ask about how their children can have the best dental health.
When Do Teeth Erupt?
Teeth will appear usually between ages 4 and 15 months. If a child has no teeth by age 18 months, they should be referred to a dentist. Usually by age 3 years, children have approximately 20 primary (or baby) teeth. Permanent teeth usually start coming in between ages 5 and 7 years, and most children have their full set by age 13 or 14 years.1
My Child Is Fussy—Is He or She Teething?
Teething begins as early as age 3 months and continues until the child has all primary teeth. Teething pain usually presents as fussiness, and babies may also have tender, swollen gums. Many parents associate fevers with teething; however, parents should be advised that fever may represent a more serious infection in a baby.2
How Do I Treat Teething?
Cold teething rings or a frozen washcloth may be used. Frozen foods, such as a banana or bagel, may also be comforting. Parents can also rub the child's gums with a clean finger. Over-the-counter teething gels are generally not recommended and can cause rare side effects such as methemoglobinemia.2 If teething pain is severe, a dose of acetaminophen may be used.2
Brushing and Flossing
When Do I Start Brushing My Child's Teeth?
Parents may use a clean cloth to wipe the child's gums prior to tooth eruption. As soon as teeth appear, parents should start brushing with a soft infant toothbrush.2
How Do I Brush My Child's Teeth?
A soft toothbrush is generally recommended. Electric toothbrushes and manual toothbrushes can work equally well if good technique is used. Parents should brush the child's teeth twice daily. An example of a good nighttime routine is to brush, read a book, and then off to bed. Most children need help brushing their teeth and flossing until they are approximately age 8 years3 (Figure 1).
A young boy practicing proper technique for teeth brushing with his dentist.
What Kind of Toothpaste Should I Use?
Toothpaste with fluoride is recommended, because it helps prevent cavities in both primary and secondary teeth. Fluoride is a safe and effective way to prevent tooth decay.4 It acts topically to help strengthen tooth enamel and prevent cavities. However, systemic ingestion of fluoride can result in fluorosis, which is a chalky appearance to the teeth; therefore, only a small amount of fluoridated toothpaste is recommended.2 For young toddlers, a very small smear, approximately the size of a grain of rice, will be sufficient. After age 3 years, a pea-sized amount is recommended.3 Parents should try to discourage their children from swallowing excess toothpaste.
When Do I Start Flossing My Child's Teeth?
When a child has two teeth that are in close contact, flossing is recommended. This typically happens between ages 2 and 2.5 years. Pre-threaded flossers may be useful when children are learning to floss.2
Establishing a Dental Home
When Should We Take Our Child to the Dentist?
The American Academy of Pediatrics recommends that parents establish a dental home for their children by age 1 year.3 As a general rule, the more teeth the child has, the earlier they should go see a dentist. Children should visit the dentist twice per year.2
What Do Cavities Look Like?
Caries often start as chalky white spots near the gum line, followed by a yellow/brown discoloration and ultimately cavitation and decay of the tooth.2
How Can I Prevent My Child from Getting Cavities?
Parents should be encouraged to have their children use bottles and sippy cups for water only to help prevent cavities. Parents should also try to discontinue bottle use at age 1 year. Children should not sleep with a bottle, especially with fluid other than water, because this leads to small amounts of a sugary substance that collects on the child's teeth overnight. Discourage frequent snacking, especially with foods that are high in sugar. Additionally, if the caregiver has active tooth decay, encourage him or her to see a dentist because cariogenic bacteria can be spread from caregiver to child.2,3
Should My Child Drink Tap Water or Bottled Water?
Tap water is recommended if the water supply source is fluoridated.2 The US Centers for Disease Control and Prevention's “My Water's Fluoride” website5 can help families determine if their water is fluoridated. The amount of fluoride in bottled water varies, and is generally not enough to help prevent cavities. If the water supply is not fluoridated, doctors may prescribe an oral fluoride supplement.2
Should My Child Get Fluoride Varnish?
Flouride varnish is a sticky substance that is applied at the dentist or medical office. Two or more applications of fluoride varnish are recommended per year. The US Preventative Task Force6 has recently recommended that fluoride varnish be applied in the primary medical home, coupled with counseling about the prevention of caries.2 For children with a moderate risk of cavities, fluoride varnish every 6 months is recommended, and for children at high risk (Table 1), every 3 to 4 months is recommended.2
Children with a High Risk for Caries
What About Xylitol?
Xylitol-containing products may help prevent cavities. In a Cochrane review,7 some evidence suggested that toothpaste with both fluoride and xylitol may be more effective in preventing caries compared to fluoride-only toothpaste, but the data about other xylitol-containing products (such as gum) is insufficient to determine efficacy.
How Do I Stop My Child from Grinding His or Her Teeth?
Many children grind their teeth. The vast majority of cases of bruxism in children are asymptomatic, and the majority do not persist into adolescence.8 Most children also do not require mouth guards. If there is obvious wear on the teeth from grinding, then the primary care pediatrician may refer the patient to a dentist in case there is an underlying genetic disease.
Will Using a Pacifier or Thumb Sucking Affect My Child's Tooth Development?
Most pediatricians and dentists recommend discontinuation of a pacifier and thumb sucking by age 3 years. Use of a pacifier or sucking the thumb may result in malocclusion. Types of malocclusion can include an open bite, a misaligned bite with abnormal overlap of the teeth, or a misaligned jaw.9
Dental health is an important part of well-child care, and should be discussed at the pediatrician's office as soon as teeth are present. Dental caries are so common that it is our duty as pediatricians to try our best to prevent them in our patients. Caries can be prevented with relatively simple measures, including proper brushing and flossing techniques, use of fluoride-based toothpaste, and behavior changes such as limiting frequent snacking or bringing bottles to bed. Many resources2–4 exist to help pediatricians and families practice proper oral care.
- American Dental Association. Eruption charts. http://www.mouthhealthy.org/en/az-topics/e/eruption-charts. Accessed October 18, 2016.
- American Academy of Pediatrics. A pediatric guide to children's oral health: a flip chart. http://www2.aap.org/oraLHEALTH/docs/OralHealthFCpagesF2_2_1.pdf. Accessed October 18, 2016.
- American Academy of Pediatrics Section on Oral Health. Maintaining and improving the oral health of young children. Pediatrics. 2014;134:1224–1229. doi:10.1542/peds.2014-2984 [CrossRef]
- US Centers for Disease Control and Prevention. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR Recomm Rep. 2001;50(RR14):1–42.
- US Centers for Disease Control and Prevention. My water's fluoride. https://nccd.cdc.gov/DOH_MWF/Default/Default.aspx. Accessed October 18, 2016.
- US Preventive Services Task Force. Dental caries in children from birth through age 5 years: screening; 2014. www.uspreventiveservicestaskforce.org/uspstf/uspsdnch.htm. Accessed October 24, 2016.
- Riley P, Moore D, Ahmed F, Sharif MO, Worthington HV. Xylitol-containing products for preventing dental caries in children and adults. Cochrane Database Syst Rev. 2015;26(3):CD010743.
- Kieser JA, Groenevelt HT. Relationship between juvenile bruxing and craniomandibular dysfunction. J Oral Rehabil. 1998;25(9):662–665. doi:10.1046/j.1365-2842.1998.00304.x [CrossRef]
- Josell SD. Habits affecting dental and maxillofacial growth and development. Dent Clin North Am. 1995;39(4):851–860.
Children with a High Risk for Caries
Those on Medicaid
Those with primary caregiver or sibling with caries
Premature or low birth-weight children
Those with special health care needs
Those with prolonged bottle use (past age 15 months)
Those with frequent snacking of sugary/starchy food