It may be challenging to teach dental care to preschoolers. They care more about what their toothbrush looks like and what the tooth paste tastes like than anything else. But, it is possible with a little help from you to get them to focus.

Correct Brushing Techniques for Preschoolers

Preschoolers don’t brush well on their own. They need guidance from you. Your assistance in the forms of demonstrations, modeling, and even singing little songs to remind them how long they should brush will all go a long way in helping them to learn properly.

In the beginning, you will probably be letting your preschooler brush their own teeth for a few minutes, with you repeating the task to ensure their teeth are sparkling clean. This is ok – kids learn by repetition. They will learn that this is their responsibility, and will get better and better at it the more they practice.

One cool things that is on the market these days is a colored tooth rinse that shows the ‘dirt’ on the teeth. When the kids brush, they can see where they missed by where they still see color. This helps them to pay better attention to all areas of their mouth.

Flossing for Preschoolers

Difficult is an understatement when describing what it’s like teaching a preschooler how to floss! It is possible, although this task will take longer than teaching them how to brush. With perseverance it can be done. Start by letting them ‘help’ by placing their hands on yours to get a feel for what must be done. Then as they grow, they’ll progress until they can do it by themselves.

Dental health lessons for preschoolers are valuable life lessons that will stay with your children all their lives. Proper dental care leads to improved health, increased self-confidence, and a better self-image for your children. Dental health lessons should be an important part of every parent’s must-do list for their child.

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Dental Health Lessons For Young Children

These basic types of toothpaste are available:

• non-fluoridated
• fluoridated
• highly fluoridated
• sensitive formula
• tartar control formula
• whitening
• with or without sodium lauryl sulftate soap

All toothpastes have pretty much the same ingredients, but try to make themselves stand out in various ways.  The most common ingredients are:

Abrasives: Abrasives are what do the cleaning in toothpaste.  They take off yellowish plaque and scrub off stains.  The most common abrasives are calcium phosphate, silica, calcium carbonate and alumina.  Toothpaste abrasives should be strong enough to remove plaque and stain, but should not be so abrasive that they damage the tooth enamel.

Coloring Agents: Coloring agents make toothpastes more attractive and more palatable.  White toothpaste has titanium dioxide and other artificial dyes make other toothpaste colors.

Detergents: Detergents cause toothpaste to foam. Foam helps keep toothpaste inside our mouths instead of running out as we brush. Sodium lauryl sulfate (SLS) is the detergent used most commonly. Unfortunately, detergents are believed to contribute to formation of  canker sores (ulcers) in some people. Detergents are bad-tasting so strong flavorings are used to hide the bad taste.

Flavoring Agents: Flavors are added to toothpaste so you enjoy using them. Most toothpastes have strong flavors to cover up the bad tasting detergents.

Fluoride: Fluoride is the active ingredient in toothpaste.

Fluoride incorporates itself into tooth enamel making your teeth more resistant to acids produced by plaque bacteria, as well as acids found in fruit juices, soda (both regular and diet) and certain foods.  Fluoride in toothpaste can be in the form of sodium monofluorophosphate, stannous fluoride, or sodium fluoride. Prescription toothpastes (for people that need more cavity fighting help such as those with dry mouth or after cancer radiation treatment, etc.) have a much higher concentration of sodium fluoride than regular over-the-counter toothpastes.

Humectants: Humectants are moisturizers and also provide smooth texture to toothpaste. Glycerin is a common humectant and sorbitol acts as both a sweetener as well as a humectant. Xylitol acts as both a humectant and as a sweetener but it is less common although it seems to be a great cavity-fighter.

Preservatives: Preservatives stop toothpaste from growing germs so you can keep the tube on your sink counter instead of in the refrigerator.  Common preservatives are methylparaben, ethylparaben. and sodium benzoate.

Sweeteners: Sweeteners also improve the taste of toothpaste. Most toothpaste sweeteners are artificial and contribute very little to cavity formation. Saccharin is a common toothpaste sweetener.

Thickeners: Thickeners, of course, determine how ‘thick’ the texture of toothpaste is. Cellulose gum, carrageenan, and xanthan gum are often used for thickening.

So what do I recommend?

• Since most toothpastes have similar ingredients, I recommend prescription 5000 parts per million Fluoride toothpaste for most people over the age of six with the caution that the reason it is prescription is that you must keep it out of reach of children (who may eat it all and get very sick).
• For kids under age two, I recommend non-fluoride toothpaste or regular toothpaste and use very little, a dry grain of rice size.
• Kids between two and six can use regular toothpaste.
• People who frequently get canker sore ulcers in their mouths should try one of the toothpaste brands without SLS such as Rembrandt.
• I recommend avoiding tartar control toothpastes because they are more acidic and can actually soften teeth as well as soften tartar.
• Sensitive teeth can be helped with one of the several sensitive toothpastes, such as Sensodyne, or come to the dentist for application of fluoride varnish on the sensitive areas.
• All toothpastes whiten teeth by removing yellowish plaque and surface stains.  Tooth whitening is best accomplished with bleaching gels rather than with toothpastes.

Just remember that cleaning teeth well has more to do with brushing technique and the use of floss than the brand of toothpaste!

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The Best Toothpaste

This is a common occurrence in children and generally happens to the front lower or front upper teeth around the age of six in most children. Some kids can begin getting adult teeth earlier, while others wait until eight years of age to lose a first tooth. pediatric shark teeth can also occur in molars and incisors as well.

How Shark Teeth in Children Happen
If an adult tooth is not exerting pressure on the baby tooth it is under, or does not have enough room to emerge, it will take the path of least resistance and grow behind the baby teeth. This makes the baby tooth root take longer to dissolve. When this occurs, the child experiences what exactly is known as shark teeth.

How to Treat Shark Teeth in Children
Have you notice shark teeth emerging in your child? If so make sure to get your child into the dentist as soon as possible.

If the dentist sees that your child’s other teeth are okay, here she will probably just have your child play with the baby tooth to try to get it to come out on its own. If it doesn’t after a period of about three weeks, then you’ll probably have to go back to the dentist to have them take care of it.

The stubborn baby tooth would be removed by the dentist to allow the permanent tooth to position itself correctly. How would position itself correctly? The teeth will be naturally pushed on by the child is here she eats talks and plays with it. This all will help it move into the right place.

Unfortunately sometimes there still is not enough room for the permanent tooth to move into position even after the baby tooth is removed. When this occurs, the dentist performs a procedure known as disking, which makes room by slimming down neighboring teeth.

Pediatric shark teeth really is not a huge issue, and many times they resolve on their own. However, if you’re worried about this, simply schedule a consultation with your pediatric dentist.

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Pediatric Shark Teeth – What Are They

In addition to regular sucrose sugar, she also used Stevia - a very sweet plant with leaves 300 times sweeter than regular sugar!  Now that got my attention.

Well, I was taken aback because I have  never heard this before and I do not know that it is valid at all.  How did she learn about this and how could I find out more?  Looking online is tricky because many of the things said about fluoride (something I have experience with) are wrong online.  Carefully looking for articles that have been reviewed by scientists seems the best approach.  Wikipedia seems like a pretty reliable source most of the time.

Several good scientific studies have looked at sugar replacements and one of the best is xylitol.  Xylitol is a “sugar alcohol”, like sorbitol, that has nothing to do with getting drunk, just explains the chemical structure of the molecule.  Xylitol, unlike sorbitol, was initially derived from birch bark and it has some very diverse and potent health benefits.

One of the best things that xylitol can do for your teeth is to stop the bacteria that eat it from growing well and this prevents tooth decay and cavities.  Xylitol gum is effective in stopping cavities in people who chew gum sweetened with xylitol, but only if they eat at least one gram each day.  Xylitol has specifically been shown to reduce the transmission of cavity-causing bacteria from mothers to their babies.

One gram a day is about two packs of gum; and xylitol gum is not cheap.  Fortunately, it is cheaper than fillings!

There are other health benefits from xylitol sweeteners such as reduced blood sugar so diabetics can use it, reduced infections, and reduced osteoporosis in women. 

I try to have an open mind about medical issues and I love the idea of using naturally occuring plants that are low calorie and provide that sweetness that we all crave while offering other health benefits too!  I have used xylitol gum for years  and I will have to try the Stevia too.

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Dietary Supplements for Dental Health

These parents love their babies and want them to have all the good things in life.  Juice is sweet and delicious and healthy too.  Right?

Fruit juice is definitely sweet and babies love it but it is not very healthy for them.  Some babies will get diarrhea from apple or grape juice and many will get cavities from drinking juice in their bottle at night.

Fruit juice has some small amount of vitamin C but it is better to get the vitamins from a slice of fruit than from the juice only.  This is because the fruit has lots of fiber with the juice that fills them up and takes the sugar to the stomach without damaging the teeth.

Juice recommendations for my Portland parents:

• Definitely no juice before 6 months.
• Children should only drink milk or water before age 3.
• Juice should only be in a cup, not a bottle or sippy cup.
• Limit juice to avoid overweight kids.
• Fruit juice in a bottle causes cavities.
• Diarrhea is caused by excessive fruit juice.
• Calcium-fortified juice should not be mixed with fluoride drops.

I joke that babies have to wait until 21 to drink beer but only wait until 3 to drink juice.  This helps drive home the message that it is ok to wait for maturity for many things in life.

Although this article is specifically about fruit juice for babies, it also applies to all other sweet drinks such as Kool Aid, sport drinks like Gatorade, and especially soda.  These sweet drinks all cause cavities and are especially bad if given to children in bottles.

Soda is one of the worst because it is sweet and fizzy.  The carbonation fizz in any drink makes them acidic and acids dissolve teeth to cause cavities.  Simply put, soda causes cavities.

Just remember that milk is the best for almost all children and that water is a wonderful drink that is healthy, cheap, and delicious!  Just remember that water from your tap is the best: safe and environmentally responsible.

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Baby Juice Bottles

A girl from Gladstone, Oregon asked me why her front teeth stuck out so far.  She was a first grader who found it very hard to stop being a thumb sucker.

Teeth are connected to jaw bones by thousands of tiny fibers that surround the roots and permit slight movements of the teeth during chewing and prevent the teeth from being dissolved away by the bone cells called osteoclasts.

These tiny fibers are called the periodontal ligament and although they are only a fraction of a millimeter long, they are critical for the health of your teeth.

Periodontitis (gum disease) results if the periodontal ligament is damaged by infection, and can lead to tooth loss.

Ankylosis (fusing of tooth to bone) occurs when the periodontal ligament is damaged by trauma and prevents tooth movement and tooth eruption.  See my article on ankylosis for more information.

What does all this have to do with braces?

Now most people would laugh at you if you told them that you could move your teeth with your fingers, but they do not think of it in terms of a thumb sucker.

My grandmother used to tell me that I could straighten my crooked front teeth if I frequently rubbed and squeezed them straight, fingers on the outside, thumb inside.  After becoming an orthodontist, now I know that she was right!  It could have worked (if I did it for more than 6 hours each day).

Well, my thumb sucking first grader from Gladstone had been using her thumb to press on her teeth which in turn stretched the periodontal ligament on one side of her front teeth and squeezed the ligament on the other side.

It happens that when bone is pulled against, it tends to grow and where there is a lack of tension, the bone recedes.  You can imagine that her thumb pushed up on the inside of her tooth and so the tooth moved up and out.

We do not know why this happens on a molecular level but we do know that the stresses and strains of life affect our bones and that the parts of bones that get worked hard grow stronger and bone that is not used dissolves away.

Apparently distortions in the structure of the bone send signals to the cells living inside and on the bone, the osteocytes, to activate either osteoblasts that make more bone or osteoclasts that dissolve bone away.

Orthodontists use the method of steady pressure on a tooth from wires or plastic to activate the osteocytes on each side of the tooth and literally grow the tooth from one place to another.

Now you know.  You should always listen to your Grandmother!

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How Braces Move Teeth

Some people have a narrow palate for a variety of reasons:

• thumbsucking
• pacificer use
• low tongue posture
• birth defects like a cleft
• mouth breathing
• unknown reasons

Depending on how the narrow palate formed, the treatment will include some intervention such as surgery for a cleft or a habit treatment.  But almost every treatment will include an appliance to widen the narrow palate if there is  a cross bite.

Crossbites are the upper teeth biting inside the lower teeth.  See this discussion of crossbites for more details of the various kinds of crossbites.

Although both sides can be in crossbite, most crossbites occur only on one side, a unilateral crossbite.  These cause the lower jaw to swing toward one side so the lower midline is moved toward the crossbite side. 

Because the lower jaw is made out of one bone, it is harder to change shape.  The upper jaw is made of two bones that can be moved more easily and effectively.  An appliance to widen the upper jaw usually works in 6 weeks and then stays as a retainer for another 4 months.

I like to use an expander that covers the posterior teeth because it helps prevent the downward movement that is usually found with expansion of the upper jaw due to biting force.

This expander is bonded to the teeth to seal out plaque and to get a very firm hold on the teeth so that they do not tip and they move the bones apart more effectively.

This bonded palatal expander moves the jaw bones relatively rapidly compared with a removable one that takes many months to widen the upper teeth (and that mostly moves the teeth rather than the bones) so it is called a Rapid Palatal Expander or RPE for short.

A RPE will almost always spread the maxilla or upper jaw bones enough to make a temporary space between the upper front incisors.  The gingiva or gums are full of stretchy collegen fibers that connect the teeth and act like rubber bands to close the space between the front teeth rather quickly.

 After correction of the crossbite, the lower jaw will move back to center the midline and the non-crossbite side moving backwards to match the joint on the now corrected crossbite side.  This is according to: Changes in condylar position and occlusion associated with maxillary expansion for correction of functional unilateral posterior crossbite in American Journal of Orthodontics and Dentofacial Orthopedics, Volume 111, Issue 4, Pages 410-418 by K. Hesse, J. Årtun, D. Joondeph, D. Kennedy.

What this tells me is that because the non-crossbite side cannot easily move backward (due to the structure of the joint), the other side has to move out of position downward and forward.  Once the upper jaw is expanded to the correct width, the lower jaw can resume the correct position and the corrected side joint will move up and back to match the crossbite side.

Overall, the RPE is a relatively quick and effective way to expand your palate for both unilateral and bilateral posterior crossbites.

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Expanding Your Palate

• crossbite
• cross-bite
• cross bite

An anterior crossbite involves the front teeth and a posterior crossbite involves the back teeth.

Rarely, the upper posterior teeth bite completely outside the lower teeth in a condition called a scissor bite. 

A posterior crossbite can involve either one side, called a unilateral crossbite, or both sides, called a bilateral crossbite.

Now that all the definitions are out of the way, lets look into why they are a problem.

All crossbites cause a shifting of normal chewing patterns.  The lower jaw works best to chew food if it is free to move not just up and down but side to side and front to back.  Think of a cow chewing its cud with the exaggerated jaw movements and you will get the idea.

When the upper jaw has one or more teeth that hang down inside the lower teeth, the full movement is not possible and a more up and down chewing movement results. 

Upper front teeth can also look bad if they are in crossbite and the lower teeth rub the front of the upper teeth.

Most seriously, the lower front teeth are much more likely to have gingival recession or other gum and periodontal problems if they are pushed forward by upper teeth in crossbite.

How can crossbites be corrected?

Anterior crossbites are corrected with an appliance that attaches to the permanent molars and pushes or pulls the upper front teeth forward.  Usually this is a rather quick procedure that might take a few months. 

Once an anterior crossbite is corrected, it will usually stay corrected if the upper teeth cross over the lower teeth enough vertically.

Posterior crossbites are usually corrected by expanding the palate, but sometimes by just moving one or two teeth. See the article on Expanding Your Palate for more on this.

Correcting scissor bites are a bit more difficult and usually requires some braces, at a minimum on the involved teeth and the opposing teeth with  a rubber band stretched vertically.  More often, braces on all the top and bottom teeth  in the area are more effective.

As you can see, crossbites can be a problem but can also be fixed  with relatively little work.

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Crossbites

Usually dentists prefer to treat infected root canal pulps before they start to hurt because this is the most comfortable way to go.  Waiting for a tooth to hurt before starting root canal treatment is usually less comfortable.

Permanent teeth with infected pulps need root canal treatment. 

The steps of root canal treatment:

• Numb the tooth with local anesthestic, usually 4% articaine or 2% lidocaine instead of novacaine.
•  
• Stretch a rubber dam over the tooth to keep saliva from re-infecting the cleaned root canal.
•  
• Remove any decay with a handpiece drill and remove the infected pulp. 
•  
• Use extremely small wire files to scrape the tissue from the canals in the roots.
•  
• Measure the length of the files to know exactly how far it is to the end of the root.
•  
• Rinse the infected material from the root canals with disinfectants, often sodium hypochlorite.
•  
• Soak triple antibiotics in the cleaned, shaped, and smooth canals to fight infection.
•  
• Pack pink, rubbery gutta percha into the root canals all the way to the tip, with runny sealer to fill in any gaps.
•  
• Place a filling in the hole and plan on a crown to hold the weakend tooth together.

Primary teeth with infected pulps are treated differently than permanent teeth. 

Primary molars last until about age 11 or 12 so we like to save them with root canal treatment, if we can, instead of pulling them out and placing a space maintainer.

Because primary teeth roots need to dissolve away when the permanent teeth start to grow in, the root canal material used for baby teeth should be dissolveable or not go all the way down the root canals.

Most of the  time, primary teeth with infected pulps are treated with a partial pulp removal called a pulpotomy.

The pulpotomy procedure:

• Numb the tooth with 4% articaine or 2% lidocaine (almost always with 1:100,000 epinepherine).
•  
• Stretch the rubber dam around the infected tooth to seal out infected saliva.
•  
• Use a handpiece to drill away infected tooth and cut the infected tooth pulp in the top coronal pulp chamber. 
•  
• Stop any bleeding with ferric sulfate, then swab out the chamber with diluted formocresol.
•  
• The infection is often only in the top of the tooth so using medicines like formocresol or ferric sulfate will treat painful nerves and kill the germs in the remaining pulp tissue.
•  
• Fill the pulp chamber with zinc oxide and eugenol filling to form a tight seal and prevent bacterial entry.
•  
• Place a tightly fitting stainless steel crown or a composite filling.

These pulpotomies are very successful for teeth that have not infected the bone supporting the tooth.  If the bone gets infected, then all the pulp tissue must be removed, even the root canal tissue, in a pulpectomy.

A pulpectomy procedure is similar to the adult root canal treatment in that files are used to clean and shape but the filling is much different.

The root canal filling material for primary teeth must be resorbable or dissolvable.  I use a material called Vitapex (a mixture of calcium hydroxide, iodoform, and silicone lubricant) with great success healing abscessed teeth. 

Pulpectomy treatment  for primary teeth is mostly reserved for only the most important teeth: the second primary molars before the eruption of the permanent molars.

When faced with the options of a painful toothache, a root canal, or an extraction, most people will be pleasantly surprised that those root canals are the best option and not an “OUCH!” after all.

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Treating Portland Pulps & Root Canals

Some orthodontists recommend treating crooked teeth or teeth that do not occlude (bite together properly) in two phases or treatment steps.  The first phase usually starts around second or third grade and a second phase around sixth grade.

Treating jaw problems early has not been well supported with excellent randomized controlled clinical trials.  These studies show that equivalent results are achieved with either one or two phases of treatment but that two treatment phases usually costs more and takes longer.

I believe that there ARE tooth alignment or spacing problems that are best treated early; before the back primary teeth come out. 

Reasons to treat early:

• Congenital problems such as cleft lips are best treated very early, then off and on for many years.
•  
• Thumb or finger sucking, pacificer use or tongue thrusting all can move teeth and even bend the jaw bones. 
•  
• Appliances to treat these problems early are very appropriate if other methods fail.
•  
• Upper teeth that stick out very far risk being broken in an accident so braces can help pull these back to safety.
•  
• Upper teeth that bite inside lower teeth are called crossbite teeth and should be treated early.
•  
• Narrow upper jaws are best treated early when the bones are most flexible.
•  
• Very crowded teeth may need to be extracted to make room for the others to straighten up.
•  
• Holding space is always a good idea with primary tooth loss.
•  
• Because the lower primary molars are usually much larger than the permanent premolars that replace them, holding this space with a metal wire appliance can usually save space for alignment without extractions.

Reasons to wait until later for orthodontic appliances:

• Two sets of braces costs more than one set.
•  
• The novelty of braces  wears off quickly so they are not so fun to wear any longer than necessary.
•  
• Putting braces on, getting straight, taking off, wearing retainers, putting braces on, getting straight, taking off, wearing retainers: just takes longer.
•  
• The longer braces are on, the more difficult it is to keep them clean and avoid cavities.
•  
• Braces come off when the second molars are straight, usually after age 12. 
•  
• Retainers for life follow orthodontic appliances so the sooner you start, the longer you will need to have retainers.

As you can see, there are some reasons to start early but if your child has crowded teeth and can wait until middle school, you and your child will be better off for waiting.

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When to Start Kids Braces?