Attention Parents and Expecting Parents!

By Brian J. Gray, DDS, MAGD, FICOI

As part of an exclusive ongoing series on oral health information for parents and children, rdental.com recently sat down with one of the leading experts in Pediatric Dentistry to gather important insight into oral health issues facing pregnant women, newborns, and toddlers.

Q & A With Dr. Brian J. Gray: "Dentistry for Prenatal, Newborns, and Toddlers"

• Does a woman's oral health during a pregnancy have any effect on the fetus?
  Yes. Studies have shown that women with many decayed teeth and advanced gum disease may have babies who are born underweight or prematurely.
• Should I take fluoride during my pregnancy to make my baby's teeth stronger?
  Maternity vitamins are especially important during pregnancy, but fluoride during pregnancy has not been shown to be of value. Folic acid is now recommended for all women of childbearing age on a daily basis, even before a pregnancy. The placenta permits only trace amounts of fluoride to pass to the fetus. The primary teeth begin to form around six weeks of gestation. They are calcifying at twenty weeks and ready to come in or erupt by birth. The second teeth begin to form after birth.
• My mouth is harder to keep clean now that I am pregnant. What can I do?
  Many women experience red, swollen gums and may seem to have an increase in dental decay with a pregnancy. This gum condition is known as gingivitis and is the result of changes in your hormone levels. One of saliva's functions is to wash away food residues from teeth. You may notice a change in the consistency of your saliva and perhaps even a sticky film on your teeth because saliva is less effective in removing the residues. The old wives' tale, that calcium is pulled from mother's teeth for the baby, is not true. The change in the diet to more frequent meals with higher sugar and starch content contributes to the incidence of dental decay. Chronic vomiting may be experienced by some women. This can cause thinning or erosion of the tooth enamel. A baking soda and water mouth rinse should be used immediately after vomiting. Good oral hygiene is always important, but especially so during pregnancy. Adding a fluoride mouthrinse to your brushing and flossing also will help to lessen some of these problems.
• What are the white patches in my newborn baby's mouth?
  Fungal or monilial infections occur frequently and may be noticed five to seven days after birth. Curdy, white patches appear on the tongue, cheeks, gums, or roof of the mouth. If these patches are removed, minor bleeding will occur. Treatment usually is not necessary, but your doctor should be notified.
• Is tongue-tie a concern?
  Tongue-tie, or ankyloglossia, is common in the newborn and frequently resolves itself. A piece of tissue called the frenum connects the tongue to the bottom or floor of the mouth. If this attachment is too short, ankyloglossia results. The only indication to have the tissue or frenum cut is if the infant cannot nurse.
• Can babies be born with teeth?
  Yes, these teeth are referred to as natal teeth. They are usually bottom front teeth or baby incisors. In most cases, these are normal teeth and should not be removed. Removal would be recommended if the tooth or teeth interfere with feeding or if looseness creates a risk of choking.
• When should one begin to clean the mouth of an infant and how?
  The inside of a baby's mouth should be wiped clean after each feeding. A clean, wet cloth or a wet paper towel may be used to gently wipe the inside of the cheeks, gums, roof of the mouth, and tongue. When the first tooth comes in, this practice is even more important.
• When does the first tooth normally appear?
  The first tooth usually appears or erupts around six to seven months of age, although there is considerable variation in the timing. Tooth eruption may even be delayed until two years of age! There are some medical conditions that will cause delayed eruption, but your physician or dentist will be aware of this. Baby teeth are referred to as primary teeth. The timing of eruption is genetically determined. Ordinarily, there are 20 primary teeth. All of the primary teeth are replaced by permanent teeth. The first primary teeth to erupt are the two bottom front teeth followed by the two top front teeth. These teeth are called the central incisors. Next come the two teeth on either side of the central incisors known as the lateral incisors, first the uppers and then the lowers. The upper and lower first primary molars are followed by the upper and lower primary canines. These teeth usually have pointed tips. The last to erupt are the four molars in the very back of the mouth. All 20 primary teeth usually are present by three years of age. This is the usual order, but just as there are variations in the time of eruption, there may be variations in the sequence of eruption as well.
• What is the best way to manage teething pain?
  Primary teeth lie just below the gums, unlike permanent teeth that develop in the bone. Some babies do experience a great deal of discomfort during teething. Massaging the gums with your clean finger can be very soothing. Excessive drooling, facial rash, restlessness, diarrhea, change in sleep and feeding patterns, colicky type behavior, and fever have been reported. About the time that teething usually begins, the antibodies, or "infection fighters" passed from mother to baby, are declining or no longer present. The baby may be more susceptible to illness at the same time as his or her own immature immune, or infection control, system takes over. Plastic teething toys should be avoided because a piece may break off and the baby's mouth could be cut or choking could occur. Teething rings should not be placed in the freezer. The frozen ring may stick to the lip, tongue, or gums and tear the tissue. Rubber teething rings containing water may be cooled in the refrigerator. Numbing medication may numb the throat and cause choking. Do not use alcohol or whiskey to numb the gums. Babies may become very ill or die with this practice. If you use Acetaminophen (Tylenol or Tempra), follow the instructions on the label carefully and consult your doctor. Too much may cause liver damage. Over-the-counter medications should not be routinely given to an infant without a doctor's approval. Do not assume that a fever or any changes in your baby are due to teething. Consultation with your doctor is always advised in order to be sure that treatment for a more serious problem is not delayed.
• Why shouldn't a baby have a bottle through the night in his or her crib?
  If a bottle is taken with the infant lying on his or her back, the contents of the bottle can be sucked into the tube that connects from the throat to the middle ear. The formula or milk can increase the occurrence of a middle ear infection. Your baby should always be in an upright or semi-upright position for feeding. The use of a bottle and even breast-feeding a baby continuously throughout the night, may cause a specific pattern of tooth decay known as "baby bottle tooth decay." As the baby sucks, the tongue covers the bottom teeth protecting them from the constant exposure to the contents of the bottle. The upper front teeth and the upper first baby molars are decayed. Abscess of these teeth may occur requiring extraction or extensive filling procedures. This problem is most often seen around 18 months to 2 years of age.
• What about the juices? Can they cause decay?
  Juice is 20 times more decay causing than milk. Any beverage other than water will cause damage to the teeth if it is given constantly in a bottle or sippie cup. Children whose stomachs' are full of liquid may have less of an appetite and eat less of the more nourishing foods. White grape juice contains more fluoride than the other juices. Consumption of white grape juice should be limited before four years of age. Apple juice may cause staining of the teeth. It should be diluted with water. Juice may be a source of vitamin C, but otherwise is not a nutritious beverage for you child.

• Is it true that the bacteria that cause tooth decay can be transferred to a baby?
  Yes, babies are inoculated with the bacteria that cause tooth decay. This bacteria is spread from the parent or caretaker to the infant by blowing on food to decrease the temperature, tasting food or sharing utensils, placing the pacifier in an adult's mouth, kissing the baby on the mouth, or sharing a cup. Babies should be kissed only on areas of their body that they cannot get to their mouths.

• How does one know if her baby needs a fluoride supplement?
  Fluoride supplements are necessary only if the baby is receiving no fluoride. These supplements may begin a six months of age. If an infant is strictly breastfed, fluoride may be prescribed. However, there are many sources of fluoride besides your tap water. Juices, bottled water, and baby foods, especially chicken, may provide enough fluoride without any additional supplementation. If your baby is in day care, check to see if the water there is fluoridated. Eight ounces of fluoridated water will supply enough fluoride for an infant each day.
• Can vitamins and fluoride be given together?
  If necessary, after six months of age, fluoride may be given with the vitamins in a liquid from. By two years of age, a chewable tablet should be taken. Vitamins should be given in the morning with breakfast, and the fluoride tablet should be taken at bedtime. Nothing should be eaten after the fluoride tablet is taken. If fluoride is taken with milk, there is little to no absorption and no benefit.
• If the baby receives only bottled water, should a fluoride supplement be used?
  Bottled water may contain significant amounts of fluoride. The time of year, the source of the water, including the water table and plant from which the water was obtained, will cause fluctuations in the amount of fluoride. Do not assume that there is no fluoride just because the water is bottled. Testing would have to be performed on every bottle in order to be sure as to how much fluoride is present.
• When should one begin brushing the baby's teeth?
  Brushing may begin with a soft-bristled brush as soon as the first teeth erupt. Do not use toothpaste. Toothpaste contains too much fluoride, the taste may be unacceptable, and the foaming may upset your child. A clean brush dampened with warm water will adequately clean the teeth. Be gentle and stay calm. If your child is crying, their mouth will be open, so take advantage of the moment, but make it only a moment! Eventually, every child accepts this as a part of the routine. Bedtime brushing is the most important time of day for brushing.
• Any toothbrush tips?
  A toothbrush with a small, rounded head is safer. Bristles should be extra soft. Rinse the brush with hot water before and after brushing. Change the toothbrush as soon as the bristles appear to be frayed. The toothbrush should also be changed after any illness. Do not permit toothbrushes to touch each other while not in use and never share toothbrushes. Do not permit your child to run or walk with a toothbrush in his mouth.
• What about pacifiers?
  Pacifiers may be used until two years of age, but that is the limit. Never tie the pacifier on a cord or ribbon around baby's neck. Do not attach a pacifier to your child for use at any time. The use should be restricted by six months of age. Parents determine the extent of the use, and the parents often create the child's dependence on the pacifier. Do not dip pacifiers in anything sweetened, especially honey. Studies have shown that pacifier use increases the incidence of ear infections, especially in children who attend day care. If the pacifier use continues past age two, there is a greater chance of deforming changes in the jaw that may require orthodontic correction. Babies are often two years apart. If discontinuing the pacifier is delayed until after age two, the task may become almost impossible. Try not to permit your child to hold a blanket or other object while using the pacifier. A precious pair may result and it will be difficult to break the pacifier habit without removing the blanket or other object as well. Some hints: Poke a hole in the pacifier bulb, dip the pacifier in white vinegar, cut the bulb off a little at a time, trade the pacifier at the toy store for something special, wrap it up in pretty paper, and send the pacifier to Santa for elf babies (you can't get pacifiers on the North Pole and Santa usually leaves something very nice in return), or pretend to give it to Auntie for her new baby. Limit the time and place that pacifier use can occur. Start with the easiest first and work from there. Bedtime is usually the hardest, but you may find that the use has stopped before you get to bedtime limitation. Sometimes, it is necessary to delay stopping the pacifier because of family problems or illness that may be resolved later. Do not condemn your little one. It is hard to break habits. Be supportive. If you truly decide it is the right time to stop, the pacifier use will stop. Most of all, hold your child. Give him or her your attention. Sometimes pacifiers are used as a substitute for Mom or Dad. There is no substitute for you!
• Can medicine harm baby teeth or second teeth?
  Tetracycline is the only antibiotic that can cause irreversible color change to the second teeth. It is no longer prescribed for children under eight years of age. Chronic illness and long-lasting high fevers may cause changes in the developing permanent teeth, but medication will not. Children's medications are colored with dyes and have a very high sugar content to make them taste good. Some pharmacies are adding flavoring to improve the taste. The combination of the dye and sugar may cause staining of the teeth. This stain is easily removed when the teeth are polished during a cleaning at the dentist. Breathing with an open mouth due to congestion and fever may also contribute to the staining. The flow of the saliva to wash away the medication is decreased, especially when antihistamines are being taken at the same time. The high sugar content will definitely contribute to decay of the teeth exposed to the syrupy medicines. Teeth should always be brushed and the mouth rinsed after the bedtime dose of medicine. Pay particular attention to brushing the bottom front teeth. The bottom lip may have to be gently pulled away to clean these teeth. The toothbrush should be changed after any illness. If your child is treated for a strep infection of the throat, two toothbrushes should be purchased when you pick up the prescription drug. The strep bacteria will be on the old toothbrush. The first replacement toothbrush should be inexpensive. Begin to use the first brush 24 hours after the medicine is begun, and use it until the medicine is finished. The second toothbrush should be a good quality toothbrush and should begin as soon as the last dose of medicine is taken.
• What about injuries to the baby teeth?
  If a baby tooth is avulsed, or knocked out, do not attempt to replace it in the tooth socket. This is not the same with permanent teeth. Attempt to find the tooth. If the tooth cannot be located and your child is coughing, a chest X-ray must be performed in order to be sure that the tooth is not lodged in a lung. The tooth could also be intruded or pushed up into the gum and bone. The can be confirmed by an X-ray. The baby tooth should come back into the mouth in six to eight weeks. Other treatment may be necessary, but not usually. Sometimes the permanent tooth that is developing in the bone just under the baby tooth is damaged when the baby tooth is pushed into the bone. The extent of the damage can not be predicted. When the permanent tooth erupts or comes in, the damage could range from a white spot to a dark indentation. If the baby tooth is lost, a space maintainer with a denture tooth can be made. This may maintain the space for the permanent tooth and improve appearance, but it is not always necessary. The maxillary frenum is the piece of tissue that connects the upper lip to the gum. If this is lacerated or cut, there will be profuse bleeding. Sutures or stitches are rarely needed. Calm your child and apply pressure. Most toddlers will not cooperate to have pressure placed on an injury to the mouth. Offer a popsicle. The coldness and lip pressure will help to stop the bleeding and as the child calms, the bleeding will slow down too.
• When should my child have his or her first dental visit?
  The American Academy of Pediatric Dentists recommends the first visit be within six months of the eruption of the first baby tooth. This is generally around 12 months of age. The first visit will involve an examination and consultation. The areas that will be evaluated and discussed are: growth and development of the teeth and jaws, pacifier or finger habit control, fluoride, management of dental injuries, the bite, nutrition and snacking, presence or risks of developing dental decay, presence of any abnormalities, and how to care for your child's teeth. Do not delay this first visit because you feel your child could not or would not cooperate. Decay in baby teeth progresses more rapidly than in second teeth. Baby teeth may erupt with an abnormal covering of enamel. Decay may appear suddenly and be followed in a short time by visible holes in the teeth. Early intervention is much easier on you and your little one than an emergency visit for advanced decay. Early intervention is the best approach. Injury to the teeth and mouth are common as children progress through crawling to walking. By establishing a relationship earlier with a dentist, you will not only have someone to call in the event of an emergency, but your child will be familiar with the dentist and the dental environment. Give yourself and your child the advantage of the best of health and schedule that first visit.