#43: Take a Bite Out of This: A Dental Primer for the Pediatrician

February 2, 2022 | By Sam Masur

Summary

Brace yourself for a fantastic conversation with UCSF Clinical Professor in Pediatric Dentistry, Dr Brent Lin. Dr. Lin’s career spans the entire age spectrum with fellowships in pediatric, geriatric and general dentistry!  He is currently the guest editor in the Dentistry Journal and an editorial board member in the Journal of Dentistry for Children. Dr. Lin fills us in on how to give great anticipatory guidance about brushing, flossing and how we can help prevent dental caries.

Credits

• Producer, Writer, Infographic: Christle Nwora MD 
• Executive Producer: Nick Lee MD 
• Showrunner: Sam Masur MD
• Cover Art: Chris Chiu MD
• Hosts: Justin Berk MD, Nick Lee MD, Christle Nwora MD 
• Editor:Justin Berk MD; Clair Morgan of nodderly.com
• Guest(s): Brent Lin, DMD

Pediatric Dentistry Pearls

1. Good oral health starts young! Promote healthy habits before the first teeth come in
2. Fluoride varnish is a safe and effective way to prevent dental caries in your pediatric clinic 
3. All children should establish a dental home by age one
4. The Dental Caries Assessment is a good way to evaluate risk of caries in your office

SPONSORS: VCU Health CE

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Pediatric Dentistry Notes

Teething and Baby Teeth

Humans have two generations of teeth, our primary (baby) and secondary (permanent) dentition. At approx 6 months of age, infants will start to have teeth that erupt until approx 3 years of age. Primary teeth are replaced by secondary teeth as a child ages (starting normally around 6 years of age) and most children will have their secondary teeth in by 18 years of age. Dr. Lin reminds us that these timeframes can vary widely. There is less concern if children are off the timeline by a few months, but if children are off by a few years this is reason enough for a prompt pediatric dental evaluation. 

Teeth may be present at birth (natal teeth) or within the first month (neonatal teeth) which are not normal. These teeth can cause issues for breastfeeding parents, and they also can be loose, leading to aspiration. 

Teething is defined as teeth eruption, and it can be characterized by fussy children with decreased appetite, swollen gums and the desire to place objects in their mouths. While some children may spike fevers in this period, Dr. Lin warns us not to assume that all fevers are associated with teething. To comfort a child with teething, Dr. Lin recommends using clean hands to take a cool cloth (or clean pacifier) and massage the gums of the infant. You can use age-appropriate dosing of Tylenol if required. He recommends against using anything frozen because that could cause damage to the gums. Dr. Lin discourages teething necklaces, creams and gels.

Caregiver Involvement in Promoting Oral Health 

Good oral health starts young! Before children develop teeth, use a washcloth to clean the oral cavity to decrease risk of fungal infections. As soon as teeth start to appear, caregivers can use a smear of toothpaste to brush the present teeth. Wipe the excess toothpaste out of the mouth to prevent any ingestion. Until children develop the manual dexterity to brush and floss, caregivers should be completing these tasks for the child. Children over the age of 3 can use a pea size amount of toothpaste. Per Dr. Lin, brand does not matter as long as it has fluoride and is approved by the American Dental Association.

How to brush your teeth: 

• Brush for two minutes with a soft bristle brush 
• Place the toothbrush at a 45 degree angle to the gums 
• Move the brush back and forth in short strokes being sure to clean all sides of the tooth
• Don’t forget the tongue and roof of your mouth!

Pediatricians should recommend caregivers establish a dental home for their child no later than 1 year of age.

Fluoride 

Fluoride is widely found in nature and has three important roles (Clark, 2014): 

1. It promotes enamel remineralization
2. It reduces enamel demineralization
3. It inhibits bacterial metabolism and acid production

These three roles make fluoride effective in preventing dental caries. Pediatricians can intervene with fluoride varnish in clinic until children have the opportunity to establish a dental home.

Prevention of Dental Caries 

Dental caries are the most common chronic disease of childhood (Segura, 2014). It is an infectious disease that is transmissible. Preventing dental caries means promoting remineralization of the tooth surface and minimizing risk factors that lead towards demineralizations. Dental caries arise in acidic environments, which can be precipitated by dietary sugar intake. Pathogenic bacteria (Streptococcus mutans is the bacteria most strongly associated with dental caries) ferment sugar, which produce acid leading towards the selection of other aciduric bacteria. This leads to demineralization, which erodes the surface of the tooth. Saliva flow can wash away food particles, provide calcium and phosphate, and act like a buffer. It is important to prevent and treat dental caries to prevent complications ranging from pain while eating to oral infections, which can lead to systemic infections. 

Baby teeth do matter! Premature loss of baby teeth or dental caries in baby teeth can impact the permanent teeth to follow. 

The American Dental Association has two dental caries risk assessment forms, one for children 6 years of age and under and another for children 6 and older.  

Dr. Lin reminds us caries are transmissible – avoid sharing utensils, and everyone in the home should have good proactive oral health habits. 

• Brushing and flossing should occur twice a day, and parents should assist until children are able to do it on their own. 
• Smear-size of toothpaste for children under 3 and pea-size (¼ inch) for older children. 
• Limit sugary foods and snacks. 
• Establish a dental home by age 1!

According to the Center for Disease Control, there are serious disparities in caries distributions across racial/ethnic and socioeconomic lines. Nearly 33% of Mexican American children ages 2 to 5 years and 28% of non Hispanic Black children had cavities in the primary teeth vs. 18% of non Hispanic white children. For older kids aged 12 to 19, almost 70% of Mexican American children had cavities compared to 54% of non Hispanic white children. In the same age group, 23% of children from low income families have untreated cavities in their permanent teeth (CDC, 2021). Some of these differences can be attributed to unequal access to dental care. 

A pediatric dentist’s goal is to save the tooth. They have a variety of options for treating dental caries ranging from fluoride treatments and fillings to root canals and extractions.

Tips for Oral Exam 

• Take advantage of a crying child to take a look inside the oral cavity 
• Use the knee to knee positioning 
• Instead of a tongue blade, try using a toothbrush (this is a much more familiar tool!)

Goal

Listeners will explain the importance of oral health and understand the pathophysiology and anticipatory guidance of dental caries.

Learning objectives

After listening to this episode listeners will…  

1. Counsel caregivers  on how to comfort the teething infant 
2. Describe the proper way to brush your teeth (including the right amount of toothpaste)
3. Be familiar with the role of fluoride varnish in preventing dental caries 
4. Explain the role of fluoride use in caries prevention

Disclosures

Dr. Lin reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Nwora C, Lin B, Lee N, Masur S, Chiu C, Berk J. “#43: Take a Bite Out of This: A Dental Primer for the Pediatrician”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ February 2, 2022.