Q: What is a cavity? What can I do to prevent them?
A: The word cavity is defined as a hollow space or hole, and a cavity in your tooth is exactly that—a hole created by tooth decay. Specific bacteria found in nearly everyone’s mouth are the main culprits. The bacteria nestle into the grooves along the chewing surface of the tooth or between two teeth, usually right underneath where the teeth make contact with each other. Then, the bacteria find the sugar they need to produce the acid that breaks down the tooth structure to create the hole. Simple sugars, like those in candy and juices, are the easiest for the bacteria to convert into the destructive acid. But more complex sugars (aka carbohydrates) can also form the same tooth-dissolving acid. Most of us know that sweets and sugary-beverages can cause cavities. But it’s easy to forget that starchy foods like chips, crackers, and bread break down into simple sugars once they enter our mouths and therefore can also contribute to tooth decay. Cavities can be prevented most effectively by daily brushing and flossing—especially after eating carbohydrate-rich foods.
However, some teeth have such deep grooves that they are nearly impossible to keep clean and will almost invariably develop decay. If these teeth are identified early, cavities can be prevented with a protective “sealant” to keep out the bacteria. Research is being conducted on selectively eliminating the decay-causing bacteria from our mouths via something akin to a vaccine, but for now we must rely on the tried and true toothbrush and floss.
Q: I think my child is going to need braces. At what age should she see an orthodontist?
A: Orthodontic treatment should typically begin when the primary teeth are lost, usually around age 12. However, when there is severe crowding of the teeth or with certain types of crossbites (when lower teeth are farther “out” than their partners on the top) it is advantageous to begin treatment sooner, often at age 7 or 8. This “interceptive” treatment helps steer growth and guide permanent teeth into a more favorable position. Most dentists should be able to advise you as to whether your daughter would benefit from seeing an orthodontist at a younger age.
Q: I have heard that having a root canal is extremely painful. What is a root canal and why does it hurt so much?
A: There is a hollow space inside each tooth that contains living cells, nerves, and blood vessels. This living tissue, called pulp, is very sensitive and can result in severe pain if bacteria reach it or if the tooth is injured via trauma. The pulp needs to be removed if it becomes infected by bacteria, or if the injury to the tooth causes significant inflammation of the pulp. Provided enough tooth structure remains to build a restoration on, removing the pulp allows a dentist to get rid of the source of the pain without removing the whole tooth. A root canal is simply the procedure by which the pulp is removed and the hollow space within the tooth cleaned out, disinfected, and sealed off so that bacteria cannot get back in. Most of the horror stories about painful root canals stem from cases where the infection around the tooth is so acute that the effectiveness of the local anesthetic (numbing medicine) is diminished. This can be avoided by seeing a dentist when symptoms first appear and with the aid of antibiotics, if necessary.
Q: What is a dental implant?
A: A dental implant is used to replace a missing tooth. In most cases it consists of three main components: the implant, an abutment, and a crown. Whenever a tooth is missing there is a tendency for the bone in that area of the mouth to wither away since it is not being “stimulated” by the pressure of a tooth. Because of their stability, versatility, and the fact that they help keep the bone around them from atrophying, implants are currently the preferred means of replacing teeth. The implant itself is made of titanium and is surgically placed within the bone where the root of the tooth would have been. It usually takes several months of “integration” time before the implant can be used to support a new tooth. During this phase the implant is usually covered by gum tissue and is not visible. Once the bone has integrated around the implant, the abutment is secured to it by a special screw. The abutment is visible within the mouth and once the gums have healed around it, a crown that looks and feels like a tooth is placed on top of it to complete the process of restoring the missing tooth. Implants can be used to support a single crown and multiple implants can support fixed-partial-dentures (bridges) as well as providing excellent anchors for removable partials and complete dentures. At this point in the field of dentistry, when a person is missing a tooth or any number of teeth, dental implants are the best choice for getting the natural tooth back. Research is being conducted, however, on the possibility of “guiding” or modifying stem cells from unerupted wisdom teeth so that they can then be placed into the bone where a tooth is missing. Much like planting a seed, these cells would develop into a new tooth that would grow up out of the gums the way our natural teeth do. Most researchers agree that we are many years away from being able to successfully plant tooth “seeds,” but it is an exciting prospect.
Q: My 3 year-old son is very attached to his pacifier. Can it do any permanent harm? I need help getting him to stop using it because I can see how it has opened his bite. What is the best approach?
A: Depending on how forcefully he sucks his “binky” and for how much time, a pacifier can move your son’s upper front teeth forward. Thumb sucking typically moves teeth even more and can be an even harder habit to end. I recommend taking a very gentle approach at first. Talk to your son about needing to stop using the pacifier because it is moving his teeth and is making it harder to bite off pieces of food. Look in a mirror together and show him the space between the top and bottom teeth when he bites down and explain that this space will get bigger if he doesn’t stop. This “rational” approach begins to be effective for children around 2 or 3, as the better understand consequences–but you have to be consistent and respectful. A gentle daily reminder can be very persuasive in the long run. Before my daughter turned 2, our pediatrician advocated simply taking her pacifier away because “at this age she’ll forget about it after a week or so and then you will be done with it.” This is true, but the bond between my daughter and her pacifier was very strong and at that time we really could not stand a week of sleepless nights just to be rid of it. So, we talked about it and regularly showed her the space between her top and bottom teeth in the mirror. We limited its use to when she was in the car or going to sleep. With pride and dramatic flare she gave it up voluntarily shortly after turning 3. But if this approach does not work and you are seeing your son’s “open bite” get worse you may have to simply take the pacifier away. The problem is you cannot take the thumb away and he may resort to it. I have found, almost without exception, that if you speak to a child respectfully they will understand and choose to stop the habit or at least forgive you for nudging them in that direction. If we shame them for it they are more likely to defiantly resist the perceived parental tyranny. Provided the child is still growing, all but the most severe cases will resolve completely a few years after the habit stops. But definitely ask your dentist to assess the impact your son’s pacifier is having on his teeth and recommend strategies suited to your son’s temperament.
Q: My 6-year old son grinds his teeth at night. We can hear him from the next room and you can see that his teeth are being worn down flat. Is there anything we can do to help him stop?
A: Tooth grinding, also known as bruxism, typically occurs during deep sleep. Nearly half of all children grind their teeth, and in most cases the grinding stops as more of the permanent teeth come in around age of 8 or 9. I have seen children who have ground their teeth down to nearly half size and stop the habit shortly after several permanent teeth have erupted. It is so prevalent that it is considered a natural part of development and very rarely requires action. But the sound, which has the uncanny ability to travel through walls and floors disturbing everybody except the bruxer, can be very disconcerting! In adults, grinding or clenching of teeth is usually associated with stress. The same may be true for children so it may help to find an activity your child finds relaxing, like listening to quiet music, taking a warm bath, or reading, and make time for it before going to bed. It’s hard to know for sure why the child is grinding. Experts speculate that some children grind because their top and bottom teeth are slightly out of alignment. By grinding, the child can smooth out the high spots and restore “even” contact. In some cases children with chronic ear infections grind their teeth to cope with the discomfort. If you feel any of these less common explanations may play a part in your son’s bruxism, ask your dentist or physician to evaluate him. In very rare cases the dentist may fabricate a “nightguard,” an acrylic appliance that looks like an athletic mouthguard, to protect the teeth during sleep. We make these routinely for adults but it is very uncommon for a child to need one.
Q: Does an electric toothbrush really clean your teeth better than a manual toothbrush?
A: The short answer is “Yes.” Clinical studies show that most electric toothbrushes afford some advantage. Of course, if your question were, “Do you recommend everyone switch to an electric toothbrush?” I would say, “No.” When a manual toothbrush is used correctly—gentle vertical or rotational strokes with bristles angled slightly towards the gums twice daily for 2-3 minutes—and in combination with careful, daily flossing, the benefit of an electric toothbrush would not be that significant. However, here’s the catch. Many of us find it difficult to implement the daily oral hygiene regimen that we know we should and so can use any extra help we can get. Also, I nearly always recommend an electric toothbrush for people experiencing a high rate of tooth decay (new cavities nearly every visit to the dentist), those at risk for periodontal disease, or patients with limited manual dexterity. Now comes the really hard part—sorting through the vast array of products to find the best one for you. The more conventional and typically less-expensive electric brushes usually either spin or rotate/counter-rotate at around 3500 cycles per minute. In general, the more expensive models that vibrate between 30,000-40,000 pulses per minute such as Sonicare, Oral-B, and Interplak, have the best clinical track record. I recommend Sonicare or the Oral-B electric toothbrushes to my at-risk adult patients. Sonicare has local roots and lots of vocal supporters, including my hygienists. Some Oral-B models combine the high-frequency pulsing with a spin/counter-spin motion that is a good choice for anyone with arthritis or other manual dexterity limitations. If you’re not sure whether you would benefit from an electric toothbrush, consult your dentist or hygienist. Just remember that flossing remains the as-of-yet irreplaceable, key component to any successful oral hygiene regimen.
Q: My child is having difficulty losing her baby teeth. Each of the four she has lost so far has “hurt” to the point where she has asked for our help in getting them out. Is this normal or should we be concerned?
A: There are a number of reasons why some children have a hard time losing their primary teeth. And while it can cause your child considerable distress, there is usually no reason to be especially concerned. In most cases the explanation stems from the child’s reluctance to “wiggle” a loose tooth with her tongue, fingers, or other teeth. Often, if a child bites down on one of her first loose teeth the painful experience “teaches” her to be very cautious. This protective instinct in turn slows down the exfoliation process, increasing the nuisance and discomfort. If your child routinely complains of pain that persists—despite the prospect of visiting the dentist about it—you should certainly have your dentist take a look. The discomfort of a loose tooth is considerable for some children and should not be dismissed, but it usually does not signal a larger problem. A primary tooth gets loose as the permanent tooth developing beneath it starts erupting (i.e. moving up into the mouth). This results in a shortening of the root of the baby tooth. As the permanent tooth gets closer to the surface, the root of the baby tooth gets shorter and the tooth itself gets looser. However, if the permanent tooth is congenitally missing or does not erupt directly underneath its predecessor the primary tooth may not get loose at all. Instead the permanent tooth can come in behind or in front of the baby tooth and may require that the primary tooth be extracted. This happens more frequently in mouths where the teeth are crowded and your dentist check on the permanent tooth by taking an x-ray. If necessary, your dentist can help get the baby teeth out with minimal discomfort and advise you of any recommended orthodontic treatment. In some cases, there may be a deficiency of a specialized enzyme that helps break down fibers that attach to the teeth and the baby teeth. They will feel like they are on the verge of falling out, but remain tenaciously adhering to the gums for a seemingly interminable stretch. While this trait is relatively uncommon, it does tend to run in families and is easily solved by seeing your dentist.