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Grand Rounds: Pediatric Dentistry


Michelle Stafford, DDS, speaking
World of Smiles
www.visitworldofsmiles.com

young woman, curly hair below shoulders, expressive hands
green skirt suit, stands behind podium so I can't see legs
nice smile, Jewish nose
fluent speaker, conversational
good awareness of naturopathic thought

herself and philosophy
her own practice started 1 year ago
emphasizes prevention, sees kids starting at age 1
free under the age of 2
mercury, BPA free, low radiation xrays

ORAL HEALTH AND CHILDREN
eruption of primary teeth begins at 6-8 months, lower incisors first then top incisors
usu in pairs
continue erupting to age 23-33 months (2.5-3 yrs)
teething: irritability, crying, low grade fever, drooling, desire to chew, food aversions
may want cold/hard food
differs from child to child, wide range
may coincide with initial oral herpes infx (in over 90% of people)
TX: camilia liquid, rub on gums, hyland's teething tablets (homeop), baby orajel, teething ring

PERMANENT TEETH
come in around age of 6
baby teeth fall out in same order they came in
last baby teeth 2nd molars usu fall out age 10-12 yrs
over-retention of primary teeth (baby teeth)
wiggle the old teeth, should be painless
new teeth come in on inside toward tongue, move forward when there's space

PRIMARY TEETH
fx for eating, speech, place holders
"life lessons are fun" sounds hard to say if no front teeth
when they get loose, wiggle them out
if permanent teeth come in and they're still in, wiggle them out

TRAUMA
most age 2-3, learning to ambulate
discoloration without early loss = nerve is dead, doesn't matter in baby teeth
very common
constant movement, trauma-->resorption of tooth root
fracture of tooth
abscess, laceration, avulsion
don't put baby teeth back in
***do put permanent teeth back in immediately
short time out of body: better chance of recovery

EARLY CHILDHOOD CARIES (ECC)
**white spots on child's tooth means enamel is weak and will progress to cavities
ECC = present of 1+ decayed, missing or filled tooth sfcs in any primary tooth
in a child 71 mo (6 years) of age or younger
etio: no brush/floss, sugary diet, oral bacteria (strep mutans)
etio: xerostomia (lack of salivary rinsing)(asthma inhalers), snacking
etio: acidic drinks, thick viscous saliva, fluoride exposure in parents
Minnesota dental association poster
sugar & acid = double trouble
coke classic has a pH of 2.4, diet schweppes tonic water, many others very very acid
*don't sip soda all day
between meals and sipping all day worst for teeth
most preventable chronic childhood dz
5x more prevalent than asthma
complications: cellulitis/infx, lethargy, transient fever, sinus infx, spread to brain
long term complic: erupting permanent molars quickly become decayed
many parents do not notice eruption of permanent molars
teeth more susceptible to cavities when first erupt

BACTERIA
Strep mutans colonization is most cariogenic
transmitted mother to child within 6 mo of life
***if mother had active decay, gingivitis, periodontitis, then avoid sharing saliva
colonization as a child adds risk for life
inhibited by xylitol: fruit, berry, corn cob, lettuce, gum

PREGNANCY
hormone-induced gingivitis/periodontitis is common
**small cavities may progress rapidly
there's a link btw periodontal dz and adverse outcomes:
pre-eclampsia, pre-term delivery, low birth weight
(link to heart dz in non-preg adults)
best time for dental tx: 2nd trimester

TRYING TO CONCEIVE
encourage dental exma and treatment completed prior to surgery
increase oral hygiene
gum with xylitol: trident, orbit
xylitol is low calorie sweetener that inhibits strep mutans
xylitol gum 5x/day is recommended

BREAST FEEDING
Dr Stafford recommends regularly scheduled feeding
at-will feedings are risky to teeth
constant feeding-->cavities
breast or bottle all night sits on teeth and weakens tooth enamel
recommends spiffies wipes with xylitol, baby tooth wipes, baby grape
wipe out mouth after feed

DENTAL HOME
AAPD recommends finding this by age 1
early visits proven to prevent cavities
parents have many questions
positive dental visits

PEDIATRIC DENTIST
got an extra 2 years of schooling
this doc has special playroom
clinic built with kids in mind
lap to lap exam: baby sits in mom lap, facing mom and lays back into examiner's lap
anticipatory guidance: prevention, diet counseling, 6 month exams
age-appropriate oral hygiene instruction
kids will brush by themselves usu around age 8, same time they're learning cursive
parents assist until then
radiographs as needed

PREVENTION
3 mo fluoride therapy if high risk
risk factors: freq snacking, xerostomia, orthodontic appliances, active dental decay
risk: parents/siblings with active decay, previous tx, white spots
risk: baby sitters, eating when away from parents

FLUORIDE
systemic vs topical: they work in two different ways
systemic:
in US up to 4ppm naturally occurring in ground water
calcium fluoride is what occurs naturally
66% of US has fluoridated water, added at 1ppm
monitored by EPA, not to exceed 4ppm
topical binds to growing teeth making them more resistant to decay
systemic use in adults: doesn't really help us at all
1945 Grand Rapids Michigan is where 1st water fluoridation experiment was done
sodium fluoride is what they add to water, a byproduct of industry
adding fluoride to water in Mi in 40-50's decreased cavities a lot
our diet is different now: eating out, sugar
big increase in cavities since 1980's
halo effect/diffusion effect: buying food grown with fluoridated water
we're getting more fluoride than we realize
fluoride is added to many infant formulas: majority of popular ones
fluoride concentrated in beverages: juice, soda, Gatorade
AAPD recommends, prescribed: .25mg for 0-3 years, .5mg for 3-6yrs, 1mg 6-16 yrs
too much fluoride can discolor teeth (darkening, yellow stripes, fluorisis past 4ppm)
topical: toothpaste, fluoride mouth rinse, helpful for adults, binds weak areas of teeth
Dr Stafford says topical better than systemic (I agree)
she recommends the use of xylitol, Europeans have been using it a long time

BOTTLES
recommends breaking bottle habit by age 1
after teeth only water in cup esp at bedtime
no pacifiers after age 3 if not earlier: can affect growth and development, speech
thumb sucking: break habit by age 3 or get crossbite where bottom teeth over top teeth
she motivates parents by talking about $thousands to pay on orthodontics dt thumb/pacifier

TYPES OF DENTAL RESTORATIONS
-amalgam/silver fillings
banned/restricted in some Eur countries: Sweden, Germany, Austria
ADA still says it's safe
she doesn't think so and her office is mercury free
she has used it working under other docs
when challenged on her choice she says "why would I take that risk"
does not cite science
-white fillings: composite or glass ionomer
white: binds better to tooth than amalgam, can remove less tooth structure
-stainless steel crowns, 100% SS no offgassing, biocompatible
don't use SS crowns in adult, use: porcelain, gold, lots more options, she likes porcelain

QUESTIONS

FLOSSING
begin when teeth are touching

ORAL PROBIOTICS
she hopes for more research in this area
she thinks we should study it
she thinks its a good idea
also considering antibiotic for strep mutans, can't use broad spectrum
she does not recommend colgate antibacterial toothpaste

TOOTHPASTE RECOMMENDATIONS FOR KIDS
crest for kids
tom's of maine "silly strawberry"

ENAMEL
weaker just after eating
rinse with water or brush after eating
if teeth weak mb not brush hard right after meal, could wear them down

BRUSH BEFORE EATING?
not a bad idea
still need to clean after meal

SEALANTS
no sealants that don't contain bisphenol A?
there is one that is BPA free, she uses it
recent product, invite your dentist to look into it
she uses sealants for deep grooves in molars because stuff builds up in the grooves

WHAT ARE MOST TOOTHPASTES SWEETENED WITH?
not xylitol
she thinks its aspartame, nutrasweet, sorbitol, something like that

COMPOSITES RELEASE BPA?
she has some composites
she says studies show no release

MOUTH RINSE THAT REBUILDS ENAMEL?
she doesn't know about that
maybe remineralize via fluoride

she uses an electric toothbrush with ionizer: sonic air

REFERENCES
www.mndental.org
www.aapd.org
www.healthychildren.org
www.ada.org

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