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Looking after babies' teeth: what can go wrong?

Brian Mouatt
CBE
Former Chief Dental Officer
Department of Health
London

Questions about the development of the teeth and oral structures are common enough among new mothers, but rarely do they turn to the dental team for answers. Very much in the front line are the nurses, health visitors and midwives who care for their patients at this vulnerable time. Some pointers to assist in this area can be useful. Certainly the outlook is optimistic - tooth decay in young children is no longer inevitable, and prevention does work. Children of healthcare workers have better teeth than average, and the old myth that bad teeth runs in the family is not true.
The story starts early, with the primary tooth buds forming at three months in utero; thumb sucking can be observed as early as seven months. Even at birth the first permanent molars, not due to erupt until the age of six, are already beginning to calcify.

What can go wrong?
It will be no surprise to learn that good nutrition is fundamental throughout pregnancy and the early years. Serious infection can interfere with the calcium/phosphorus balance and cause weakness in the tooth structure; prescribing of the tetracycline group of antibiotics during tooth formation can result in severe and disfiguring staining of the teeth, and very premature babies are vulnerable for all the obvious reasons. However, the main problems arise at or around the weaning stage, as the first teeth begin to come through.
Dentists are very much in favour of breastfeeding because the muscles of the oral cavity and tongue, which are complex, need the stimulus to develop well. In turn, the forces exerted during suckling influence the shape of the jaws and the teeth within them. Because of the nipple design, bottlefeeding often does not provide these muscles with a sufficient challenge and can lead to less than optimum muscle and tongue strength.
The timing of the eruption of the first teeth is quite variable but the lower incisors usually appear first, followed by the uppers at around four to eight months. After the eight incisors appear, the first primary molars erupt at about 12 months. These teeth are especially vulnerable to decay as they have flat surfaces with fissures. The canines follow at about 18 months, and finally the second primary molars at two years; they too have fissures that can trap food. The primary dentition of 20 teeth lasts complete until 6 or 7 years, when it is gradually replaced by the permanent dentition, a process that goes on until the age of 12 years. Wisdom teeth come later, between the ages of 18 and 22 years. These teeth are for life, and this development should be monitored regularly by dental professionals. 
Of course as soon as any teeth erupt they are vulnerable to attack by acids formed from sugars by the bacteria in plaque. Cleaning should start as soon as they first appear. Sometimes a small piece of damp gauze is easier to manage than a toothbrush in a wriggling baby. The key to success is a clean mouth free of lingering food debris. That is why a drink of water at the end of feeding is such a good idea. Water is also the best "between meals" drink.

Early problems
There are a number of conditions that may arise. Sometimes, shortly after birth, small keratinised white patches are seen in the palate. They are known as Epstein's pearls and can be mistaken for misplaced and unerupted teeth. They are in fact of no significance and will disappear in about two weeks.
Occasionally teeth are found erupted at birth or shortly afterwards. These should also be left alone except in very rare circumstances: for example, when feeding is seriously disrupted. Later, small eruption cysts may develop - resist any temptation to open or cut them as infection may result. This consequence is sometimes seen in African communities, where it has cultural origins. 
Advice on pacifiers is always welcome - the dental profession has become much more relaxed about the use of these aids to serenity, and their design has improved. Never hang a pacifier round an infant's neck with a ribbon or cord. This dangerous practice has been known to result in strangulation. The pacifier should be of modern, sturdy design with a shield or mouth guard incorporating ventilation holes. The nipple should be inspected frequently for wear and tear, and the pacifier replaced if necessary. It almost goes without saying, but honey- or sugar-dipped nipples are never permissible. This practice can rapidly strip the enamel off the first teeth and lead to rampant decay - known to dentists as "bottle caries". The same applies to pacifiers with reservoirs; they look like a good idea but are dangerous.
Tongue-tie worries parents. Most children grow out of it, but if it persists into the toddler stage then it is usually sufficient to remain aware of the problem and monitor it. Surgical intervention carries with it the risk of fibrous scarring, which can affect the later development of the teeth.

Teething
Pain associated with teething is best tackled by keeping the mouth very clean using damp gauze. Teething rings are useful to speed the process. The associated drooling is quite natural and can be ignored except for aesthetic reasons.

Stains
Parents often worry about stains on the teeth. Generally there are three types, but of course dental caries must first be excluded. A green stain is usually removable with toothpaste and gauze. A black stain is retained pellicle and is more difficult to remove. Professional cleaning with dental instruments may be needed. Some children exhibit an orange-coloured stain due to chromogenic bacteria. Like the other superficial stains, this does no harm but may be a marker for future susceptibility to dental caries and indicates preventive advice and close monitoring. Intrinsic stains and discolorations within the tooth structure almost always need a professional assessment and may be due to fluorosis, enamel  defects or, rarely, inappropriate tetracycline prescribing.

Thumb sucking
Sucking habits should be regarded as a necessary part of the teething process and should be discouraged only with gentle persuasion and not allowed to develop into a battle of wills. Usually the habit ceases naturally and should have become less of a problem by the time the permanent teeth arrive. Persistent sucking after this may indeed cause dental problems, affecting the position of the teeth. Advice should be sought from the dentist, who will at the right time be able to offer orthodontic advice or referral. Orthodontics is very rarely needed before the permanent teeth are well established. Starting too early can lead to unnecessarily long periods of treatment. The best age is usually around 12-13, so there is no need to panic about the position of baby teeth.

Tackling tooth decay
It is never too soon to visit the dentist! Getting used to the surroundings and smells of the family dental practice is a good start, and a ride in the dentist's chair can actually be fun. Sadly, all too often, especially in needy families, the first visit is for toothache, which is not fair on anyone - mother, child or dentist!
There is no doubt that socially and economically deprived families with children are the most vulnerable to dental decay. It is now clear that the best way to protect a baby's teeth against decay is regular brushing (twice each day) with a fluoride toothpaste. This should start the moment the first teeth begin to erupt. It is necessary to use only a smear of toothpaste on the brush. For most children a specially formulated paediatric toothpaste will provide sufficient protection and reduce the slight risk of mottling developing in the teeth from fluorosis if too much is accidentally swallowed. 
For children of deprived families, for whom the risk of decay may far outweigh the minor cosmetic risk of fluorosis, an adult-strength fluoride toothpaste may be recommended by local dentists.
To help mothers with young babies, an instructive new leaflet, "Looking after your baby's teeth", has been produced as a direct carrier of the preventive messages to these groups. It has a very simple approach - use fluoride toothpaste and limit the frequency of intake of sweet things. Dentists now know that it is the frequency of exposure to these foods and drinks rather than the quantity that gives rise to decay problems. It is hoped that this new leaflet will be useful to all coming into contact with mothers and babies. And best of all, it is free.

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Resources
The Sugar Bureau
Duncan House
Dolphin Square
London SW1V 3PW
W:www.sugar-bureau.co.uk

British Nutrition Foundation
High Holborn House
52-54 High Holborn
London WC1V 6RQ
W:www.nutrition.org.uk