Dental Care for Infants and Young Children: Part One

Image by Mojca JJ from Pixabay

This is the first in a series of articles where we will discuss how to get your baby and/or young child's teeth off to a good healthy start.

Image by Lubos Houska from Pixabay

Good dental health starts before a child is even born.
Teeth start to develop 6 weeks into pregnancy.
By 3 months into pregnancy, the developing baby already has enamel forming in the front incisors.  By 4 months the enamel is already forming in the back molars.  
Since tooth enamel is mostly made from calcium and phosphate, during pregnancy, try to include foods in your diet that are rich in calcium and phosphate such as cheese, milk, meats, poultry, fish, green leafy vegetables, nuts, seeds, beans, and fruits.​

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As well, physicians recommend that women start taking a daily prenatal vitamin (for example, Materna), one month before they try to conceive, then during the pregnancy and even after they deliver  if they are breastfeeding.  A prenatal vitamin will ensure you are getting all the essential nutrients you need during pregnancy especially iron and folic acid, which is very important in normal spinal cord and brain development during the first 20 weeks after conception.

When Do Teeth Start to Erupt?
The first baby tooth usually comes in when the baby is 5 or 6 months old, but sometimes later. This may be accompanied by teething pain. So here are a few tips:

• If the baby is very fussy, you can give liquid Acetaminophen or liquid Ibuprofen.

• Please don't put a numbing gel on the baby's gums, especially gels containing benzocaine or lidocaine, as they can be toxic, even fatal if the baby swallows too much of it.  
• You can also let the baby chew on a cooled, not frozen, teething ring.
• ​At the end of this post I will include links to two good articles on teething.

When Can I Start to Use Toothpaste?
Once the baby's first  teeth come in, you should start cleaning them with a soft infant toothbrush with just water on the brush, twice a day, or you can use a piece of wet gauze. This will keep the plaque or bacteria off the teeth and prevent cavities from starting. In children under 3 years of age, just water on the brush is fine.

If the child has already had cavities or has signs of cavities starting, you can use a small bit of fluoridated toothpaste but just the size of a grain of rice. A child under 3 years of age will probably swallow the toothpaste rather than spit it out, so it is better to minimize the amount of fluoride a young child is ingesting.

A Grain of Sand Amount of Toothpaste

Once the child turns 3 years of age and the child can spit out,  a pea-sized amount of toothpaste containing fluoride is recommended on their toothbrush. ​

A pea-sized amount of toothpaste

​Using more than a pea-sized amount of toothpaste can again result in the child swallowing too much fluoride, which can result in a condition called fluorosis. 
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Fluorosis is a  common condition. It is caused by a tooth being exposed to too much fluoride while it is developing. A tooth with fluorosis will have small white flecks on its enamel surface. It can occur in baby or adult teeth. It is usually barely noticeable. It does not mean the enamel is weak. It is usually a non-issue. The time when fluorosis can develop in teeth is between birth and 8 years of age when the enamel of baby teeth, and later permanent teeth, is forming under the gums.

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Mild fluorosis of permanent teeth

The advantage of using a toothpaste with fluoride is that if your child is developing a cavity, the fluoride, when brushed onto the tooth, can penetrate damaged enamel, repair and sometimes reverse cavities.
An important note: Be sure to keep toothpaste out of reach of young children.  

Fluoride is beneficial in small amounts; however in large amounts it can make a child feel very sick. If a child eats more than half a tube of toothpaste, you need to call your local poison control hotline as it can become a health emergency. There is more information on this at the website kidsmergencies.com 
http://kidemergencies.com/toothpasteingestion.html

Parents should brush their child's teeth for them until they are about six years of age. If young children are left to brush on their own they are going to miss spots. Another way to prevent cavities in young children is to floss for them once a day. This is helpful once their teeth start to get close together. Most kids won't have the dexterity to floss effectively on their own until they are about 10 years of age. 

Image by Boris Trost from Pixabay

Fluoridated Water and your child's teeth








​Fluoride is a naturally occurring mineral in water. If you live in a place like Toronto, Canada, where I live, fluoride is added to the drinking water as a public health measure to reduce cavities.

The optimal amount of fluoride concentration is 0.7 mg of fluoride per litre of water or 0.7 parts per million fluoride. This can reduce cavities in children by 20 to 40 percent.

​In the United States, about 72% of communities have fluoridated water. In Canada, only about 38% do. 

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An important point is that fluoride only benefits a tooth once it erupts into the mouth where it can make direct contact with a tooth. When our teeth are forming under the gums, they do not need fluoride to develop strong enamel.  

How does Fluoride Benefit a Tooth?

Even very young children can develop cavities. Our teeth are covered with bacteria or plaque. Even after we brush, bacteria starts to regrow on our teeth. 

If you eat something with sugar or any white starch, the sugar or starch will feed the bacteria on our teeth and the bacteria will produce acid. This acid will start to break down the enamel on the surface of the tooth. This is how cavities start.  

If your child drinks fluoridated water, both the enamel and the plaque are bathed in fluoride. The fluoride gets deposited into areas where the enamel is starting to decay and rebuilds and hardens it. 

Fluoride is also antibacterial. It penetrates bacteria on our teeth preventing the bacteria from producing acids that cause cavities.

​If you drink fluoridated water, fluoride will be present in the saliva produced by our body. So your teeth will continue to be bathed in fluoride even after you have swallowed that gulp of water, again helping to rebuild teeth that are starting to develop cavities.

Here are some additional things to consider about fluoride 

• If you are unsure whether your drinking water is fluoridated you should contact your local water department. They should be able to tell you the known amount of fluoride in your tap water. 
• If you drink well water, you should contact your local public health unit to get the fluoride level in your water tested.  
• The natural ground water in some areas has low levels of fluoride while some areas have very high levels of fluoride so it would be helpful to know how much fluoride is in your water, especially if you have children under 8 years of age.
• ​If you determine your drinking water is less than 0.7 ppm fluoride you may decide, after consultation with your dentist to give your child a fluoride supplement but be very cautious about this because giving too much fluoride to a child can result in moderate to severe fluorosis.
• If your family only drinks bottled water, you should ideally look for a brand that offers approximately 0.7 to 1 ppm fluoride.
• If your water source has a fluoride content higher than 2.0 ppm fluoride you might be best to use  bottled water than has a lower fluoride content.  
• Children drinking water that is above 1.5 ppm Fluroide can develop fluorosis and drinking water above 2.0ppm can result in moderate to severe fluorosis.
• Moderate or severe enamel fluorosis can be quite cosmetically disfiguring.  The enamel of the teeth can have large white or brown blotches and many of the teeth, often permanent teeth can be affected. 

A Note About Bottle Feeding Using Fluoridated Water

If you are unable to breastfeed and you are using infant formula, there are a few types available:

1. Powdered formula that needs to be mixed with water
2. Concentrated liquid formula that needs to be mixed with water.
3. Ready-to-use formula that does not require mixing with water

During the first six months after a baby is born, the baby will not be eating solids. During this time, if you are using powdered or concentrated formula that requires mixing with water, and formula is the baby's main source of nutrition, you may be best to alternate between fluoridated and unfluoridated water i.e. bottled water.

• If you only use fluoridated water during these first six months in the formula, your baby could develop very minor dental fluorosis or white spotting of their teeth that are still forming under the gums. I am basing this on water that is optimally fluoridated i.e. between 0.8 ppm and 1.4ppm fluoride. But it would be very mild, so you shouldn't stress about it if you need to only use tap water.

Once the baby is 6 months old, they likely will start to eat solid foods as well and as a result drink less formula, so fluoridated tap water is fine.

Breast milk or ready-to-use infant formula is safe for developing teeth.

Do Home Water Filters or Purifiers Remove the Fluoride From Tap Water?

Home activated carbon filters, like Britta, only remove trace amounts of fluoride from the water, so from a dental point of view, they are perfectly fine.
Other home water filters that do remove the fluoride from water use the following technology: Reverse osmosis, gravity filters, water distillation and others.

If you use a home water purifier and you want to see if it removes the fluoride content from your water, you are best to check with the manufacturer.

Well, we have covered a lot of information in this article. Below are the reference articles I used if you care for further information. I will be writing further articles on children's dental health as there is a lot more important information I would like to share with you.
If you have any questions or comments or topics you would like me to discuss, please feel free to use the comment section below.
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Best regards,
Dr. Jeff Shnall  DDS   Beech Dental    Toronto, Ontario

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Reference Articles

Links to Good articles on teething:
1.  From the Website "What To Expect" (WhatToExpect.com)
     https://www.whattoexpect.com/first-year/teething/

2. From the Mayo Clinic Webite:  Teething:  Tips for Soothing Sore Gums.  www.mayoclinic.org/healthy-lifestyle/infant-and-toddler-health/in-depth/teething/art-20046378

Regarding the use of fluoride supplements for children:
The American Dental Association https://www.ada.org/en/member-center/oral-health-topics/fluoride-topical-and-systemic-supplements

Water fluoridation: a critical review of the physiological effects of ingested fluoride as a public health intervention.  Peckham S, Awofeso N.  ScientificWorldJournal. 2014 Feb 26;2014:293019. doi: 10.1155/2014/293019. eCollection 2014.
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The Canadian Paediatric Society. The use of fluoride in infants and children. J Godel; Canadian Paediatric Society, Nutrition and Gastroenterology Committee
Paediatr Child Health 2002;7(8):569-72.  Posted: Oct 1 2002 | Reaffirmed: Feb 25 2019.
https://www.cps.ca/en/documents/position/fluoride-use

Teething: Tips for soothing sore gums. Mayo Clinic. By Mayo Clinic Staff.
https://www.mayoclinic.org/healthy-lifestyle/infant-and-toddler-health/in-depth/teething/art-20046378

The State of Community Water Fluoridation across Canada.  Public Health Agency of Canada.
Published:2017-12-15 
https://www.canada.ca/en/services/health/publications/healthy-living/community-water-fluoridation-across-canada-2017.html

2016 State Fluoridation Percentage calculations and States Ranked by Fluoridation Percentage.
https://www.cdc.gov/fluoridation/statistics/2016stats.htm

Chronic Fluoride Toxicity: Dental Fluorosis.   Pamela DenBesten and Wu Li.  Monogr Oral Sci. 2011; 22: 81–96.Published online 2011 Jun 23. doi: 10.1159/000327028 NIHMSID: NIHMS368844​​