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Pediatric  Dental   Health

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How Much Fluoride Is Enough?
Your child may be getting more fluoride than you think! Children ingest fluoride from a variety of sources, some of which are not well-known. Excessive fluoride ingestion by preschool-aged children can lead to dental fluorosis, which is an unsightly discoloration of the adult teeth. Parents can take specific steps to decrease the risk of fluorosis in their children's adult teeth.

Dental fluorosis is the result of excessive fluoride ingestion by young children during tooth development early in life. The increased prevalence of fluorosis is due to the cumulative effects of:
1. Use of fluoridated toothpaste before the age of two.
2. Inappropriate use of fluoride supplements.
3. Hidden sources of fluoride in a child's diet.

Two- and three-year-olds may not be able to expectorate fluoride-containing toothpaste when brushing. As a result, these youngsters may ingest an excessive amount of fluoride during toothbrushing. Toothpaste ingestion during this critical period of adult tooth development is the greatest risk factor in the development of fluorosis.

Excessive intake of fluoride supplements may also contribute to fluorosis. Fluoride drops and tablets, as well as fluoride fortified vitamins should not be given to infants younger than six months of age. After that time, fluoride supplements should only be given to children after all of the sources of ingested fluoride have been accounted for.

Certain foods contain high levels of fluoride, especially: powdered concentrate infant formula, soy-based infant formula, infant dry cereals, creamed spinach, and infant chicken products. Some beverages also contain high levels of fluoride, especially: decaffeinated teas, white grape juice, and juice drinks manufactured in fluoridated cities.

Parents can take the following steps to decrease the risk of fluorosis in their children's teeth:
1. Use baby tooth cleanser on the toothbrush until your child is 2 1/2 years old.
2. Place only a pea-sized drop of children's toothpaste on the brush from age 2 1/2 to 8.
3. Account for all of the sources of ingested fluoride before requesting fluoride supplements from your child's physician or dentist.
4. Avoid giving any fluoride-containing supplements to infants until they are 6 months old.
5. Obtain fluoride level test results for your drinking water before giving fluoride supplements to your child.

Learn more about Fluoride.

Can Deep Stains Of Children's Teeth Be Treated?
Many children have persistent stains of their teeth which cannot be removed by brushing or professional dental cleaning. These discolorations may represent: enamel stains, enamel dysmineralization, or dentinal stains.

Deep stains may be caused by: compromised enamel development; high fever or intake of certain medications during early childhood; previous trauma caused by a displaced or intruded baby incisor; previous dental infection or abscess of a baby tooth; or direct trauma to the erupted adult incisor.

The actual method of treating dental staining must take into account: the color and darkness of the stain, the extent and location of the stain, the number of teeth affected, the age and cooperation level of the child, and the putative cause of the dental discoloration. Treatment of stains will involve one or more of the following procedures: bleaching of the stained tooth, removal of the stained enamel, or covering up the stained area.

Dental bleaching is useful in many situations. Bleaching can also be used in combination with microabrasion of the affected tooth. Tetracycline-stained teeth are difficult to bleach, however, because this drug-induced stain resides in the dentin layer, which lies under the enamel.

The active ingredient in dentist-prescribed home bleaching is a 10% carbamide peroxide gel. The parent places this high-viscosity bleaching gel in a custom-fitted bleaching tray. The child then wears this bleaching tray for two hours per day for two months, or until the stain is gone. Only five dentist-prescribed, home-use bleaching products currently have the ADA Seal of Approval. No OTC bleaching gels have this seal.

If bleaching is ineffective in removing the stain, and the defect is limited to the enamel layer, then microabrasion is performed next. Enamel microabrasion is the removal of dental stains using a combination of acid and abrasive. According to Croll et al, "Enamel microabrasion is useful for the removal of superficial enamel dysmineralization defects and decalcification lesions." "Both dental bleaching and enamel microabrasion can be used for children as young as six or seven years."

The last option for treating stained teeth is to cover up the discolored areas with cosmetic bonded materials. In this technique, the surface of the tooth is covered by either a composite resin material or a porcelain veneer. Due to cost issues, however, most of the bonded cosmetic veneers for children utilize a microfilled bonded composite resin.

A journal article describes techniques for treating dental stains in children:
Croll T, Segura A. Tooth color improvement for children and teens: Enamel microabrasion and dental bleaching.
J Dent Child, 63:17-22, Jan-Feb 1996.

Can Teeth Be Pushed Up Into The Gums?
Baby teeth can be pushed up "into the gums" and supporting bone during a fall or traumatic event. This kind of dental trauma is called an intrusion injury, and can affect the developing adult tooth buds. Most intruded primary teeth re-erupt on their own.

Intrusion injuries are most common in 2 and 3-year-old children. Young toddlers are still learning how to walk and run, and their coordination is limited. When toddlers fall, their teeth are usually subjected to a vertical, intrusive force. Dental trauma in older children, however, is often associated with horizontal forces to the teeth, resulting in a greater number of tooth fractures and avulsions.

Intruded primary incisors may pose a threat to the developing permanent tooth buds. Only a thin layer of bone separates the root of a primary tooth from the follicle of the permanent tooth. If the root tip of the baby tooth impales the developing adult tooth, problems will occur with normal adult tooth development. An extra-oral, lateral-anterior radiograph will show the position of both primary and permanent teeth.

Most intruded baby incisors will re-erupt within 1 to 6 months. Intruded teeth which threaten development of the permanent tooth bud, however, will need to be extracted. According to Holan et al, "The majority of intruded primary incisors may re-erupt and survive with no complication after more than 36 months post trauma..."

Parents should take the following steps when a baby tooth has been displaced or intruded:
1. First, take your child to a physician to rule out other injuries, neurologic damage, or airway obstruction. The physician will provide a tetanus toxoid booster or antitoxin injection, if necessary.
2. Next, take your child to a pediatric dentist for an evaluation. He/she may need to use gentle restraint to examine your child's teeth and oral structures. Your child may need to sit on your lap when dental radiographs are taken. You may also be called upon to provide gentle restraint during the examination and x-ray procedures. The dentist may need to take both an "occlusal" and a "lateral-anterior" radiograph of the teeth.
3. Request periodic dental re-evaluations for your child.
4. Brush and clean our child's teeth every day, especially around the intruded tooth.

A recent journal article discusses this topic:
Holan G, Ram D: Sequelae and prognosis of intruded primary incisors: a retrospective study.
Pediatric Dentistry 21:242-47, 1999

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