Infant Teething and Toddler Tooth Care – PediaCast 423

Show Notes


  • Dr Janice Townsend is Chief of Dentistry at Nationwide Children’s. She joins us to answer questions about infant teething and tooth care for babies and toddlers. We explore symptom relief, brushing, fluoride, cavities, thumb-sucking and pacifiers. We hope you can join us!


  • Infant Teething
  • Tooth Care for Babies and Toddlers
  • Toothbrushes and Toothpaste
  • Benefits of Fluoride
  • Preventing and Treating Cavities
  • Thumb-Sucking and Pacifiers




Announcer 1: This is PediaCast.


Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children's, here is your host, Dr. Mike.

Dr. Mike Patrick: Hello, everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children's Hospital. We are in Columbus, Ohio. 

It is Episode 423 for February 7th, 2019. We're calling this one "Infant Teething and Toddler Tooth Care". It is a tongue twister today. Try to say that ten times fast, Infant Teething and Toddler Tooth Care. No, I won't do it nine more times.


I do want to welcome you to the program, though. It's an important topic today, especially if you have a baby or a toddler in the house or if you are expecting to bring a baby home sometime soon. Lots of questions that parents have about teeth in this young age. What should you do when babies teeth start coming in? What signs and symptoms go along with teething? 

And, of course, there are lots of myths and misconceptions at play as we think about teething and how we take care of baby teeth. And so we're going to try to settle some of those and get you evidence-based facts into your hand. What can you do to help a teething baby achieve comfort, for instance? 

I mean, what's the best practice when your baby is fuzzy, and you think it's because their teeth hurt or their gums hurt? What can you do to help them out? What strategies should you avoid and why should you avoid them? 

Then, we will transition to the care of baby teeth in both infants and toddlers. When should you start brushing a baby's teeth? What would you use? Do you just water or do you do toothpaste? 


If the answer is toothpaste, when do you start? What kind do you use? Should I have fluoride in it or no? And how much toothpaste should you use with each brushing when you do start using it? What other cavity prevention strategies should moms and dads consider? 

And then, what about fluoride? You hear about this in the toothpaste but it's also available in nursery water that you can buy in the store. Tap water may have it. Your well water may actually have some natural fluoride. It might even have too much natural fluoride. And then, there's the oral drops that can be prescribed. There's tooth varnish that can be applied to the teeth. 

So which one should you use? Are these products safe? How much is too much? Can you do multiples or is that going to be too much fluoride? I mean, lots of questions to consider when it comes to teeth and again, particularly in babies and toddlers. 


What about when you do get cavities? When a cavity hits a baby tooth, how do we treat that? And then, how about pacifiers and thumb sucking? So pretty much everything you need to know to successfully navigate oral healthcare for the youngest of kids.

So lots of terrific information today especially if you are responsible for taking care of baby and/or toddler teeth. Now, let's say that does not describe you. You have teenagers at home. Please allow me to suggest a couple of options. One, you can abandon this episode and find one that piques your interest and meets your unique parenting needs. You're not going to offend me. 

I mean, we have an archive of 422 other episodes over at and roughly a quarter of those or just over 100 episodes, the most recent ones are available on the feed. So you can find those in Apple podcasts, Google Play, most mobile podcasting app. You should be able to find something easily that matches your interest and what you're thinking about these days.


If you go that route though, before you leave, please, before you abandon this episode, please consider sharing this particular topic with folks who do have babies or toddlers at home or families who are expecting babies. It should not be too difficult for you to share the show. We try to make it as easy as possible. If you just check out our social media feeds over the next few days, we'll be promoting this particular episode. Just search for PediaCast in Facebook, Twitter, Instagram. And just let your peeps know about the program because they may have a baby or toddler at home and really be able to get something out of this information.

Another option for you. Even if you don't have a baby or toddler in the house, but let's say you just love science and you love childcare topics for their own sake, like me, then you may want to stick around because we have a fantastic guest to walk us through the ins and outs of baby teeth.


Dr. Janice Townsend is Chair of Pediatric Dentistry at the Ohio State University and Chief Pediatric Dentist at Nationwide Children's Hospital, so she knows a lot about baby and toddler teeth. And just like you, I'm looking forward to learning more about infant teething and tooth care from her. Doctors don't get a lot of teeth education in medical school. And then by the time you're out practicing, you kind of forget a lot of the little minutiae that you learned and didn't have to deal with on a daily basis as you went through your residency training.

A lot of us, I think, have questions about the proper way to care for teeth and Dr. Townsend is going to help us understand that more clearly. If all these strikes your fancy, stick around. Dr. Townsend will be joining us in just a few moments. 

First, though I mentioned sharing the show on our social media channels. Yes, we do promote the show on Facebook and Twitter. Just look for PediaCast and please consider liking us. And especially on Facebook and Twitter, where we not only promote the program but we also try to provide throughout the day just some news articles that I think would be interesting for parents.


So what exactly am I talking about? Just some recent examples, I shared an article on this idea that more screen time for toddlers is actually tied to develop mental concerns down the road. If you look at like two and three-year olds, then when they become four and five-year olds, the more screen time that they were exposed to, the more chance there is more risk or a developmental problems as they get a little older. 

So spending some time away from the screen, playing with other kids, with mom and dad, getting down playing with things with your hands and being creative is very important part of the developmental process. And that does not translate well to a screen. Sure, I mean, there's lots of cool things that are on screens but the things that babies and toddlers need to develop appropriately are not there. So that's a good article.


Also another one, you may have heard of pump and dump, which is this idea that if you drink alcohol while you're breastfeeding, just drink the alcohol and then go ahead and pump and dump the milk because it's going to have an alcohol in it. That's actually a myth. And this article explains why it's a myth and how you can have an alcoholic beverage and still breastfeed safely without wasting any of your breastmilk.

So it's a terrific article from Dr. Phil Boucher. He's another pediatrician and colleague of mine from another part of the country and he explains why pump and dump is a myth. So we share that.

Also, a warning from CDC, the Centers for Disease Control and Prevention. They say do not kiss or snuggle your hedgehog, okay? Don't do it. Don't kiss or snuggle your hedgehog. They can give you salmonella. If you'd like to know more about that, check out our Facebook and Twitter.


We also have been talking about measles outbreaks because there have been more of those in unvaccinated folks. And the measles, it can cause deadly pneumonia. It's very, very contagious and for every thousand cases, you can expect one or two deaths even with the best medical care, so it is potentially deadly illness.

And there's also been some news recently about  measles. When you actually have an active infection with the measles, it wipes out the memory. This is a theory but it's a pretty good theory based on observations. And that is that it somehow, and we don't really understand how or why, it wipes out the memory for other illnesses that you've had. 

So that if you have the real measles infection and let's say that you had a really bad case of chickenpox before you had the measles, then after the measles, you could get chickenpox again. Or you could get any number of bacterial infections again or viral infections for that matter.


So not only this measles affect you when you have the illness but it could also affect your immune system down the road as opposed to the measles vaccine which protects you from measles, and in that way also protects that damage from occurring down the road to your immune system. So we've posted some articles related to that sort of thing, again, in our social media feeds. 

And then the tips for making family meals routine again. A lot of times we're so busy that we don't have time to sit down at the dinner table, and these are just some ideas for getting the family together for meals. So you can check out also again in Facebook and Twitter. 

Don't forget, you can also suggest topics for this program. There's a topic you'd like to hear about, you have a particular question for me or you want to point me in the direction of a news article or a journal article, really easy to get in touch, just head over to and click on the Contact link. 

We also have a phone number if you'd like to leave a message. It's 347-404-KIDS. That's 347-404-5437.


Also, I want to remind you the information presented in every episode of our podcast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you have a concern about your child's health, be sure to call your doctor and arrange a face-to-face interview and hands-on physical examination.

Also your use of this audio program is subject to the PediaCast Terms of Use Agreement which you can find at

All right, let's take a quick break and then I will be back along with Nationwide Children's chief pediatric dentist, Dr. Janice Townsend, as we explore infant teething and tooth care. That's coming up right after this.



Dr. Janice Townsend is the chief of Dentistry at Nationwide Children's Hospital and associate professor of pediatric dentistry at the Ohio State University, College of Dentistry. She's here to talk about baby teeth as we consider infant and toddler teething, tooth care, and cavity prevention. So let's give a warm PediaCast welcome to Dr. Janice Townsend. Thanks so much for being here today.

Dr. Janice Townsend: Thank you for having me.

Dr. Mike Patrick: I really appreciate you stopping by. So one of the first things that parents wonder when they have a new baby is when is the first tooth going to pop through. When can we expect babies to start teething?


Dr. Janice Townsend: Normally, teeth starts to erupt around six months of age. And the first teeth to erupt are going to be the mandibular incisors which is fancy talk for the lower front teeth. And soon after that, there's maxillary incisors or the upper front teeth are going to start coming through as well.

Dr. Mike Patrick: So start in the middle of the bottom and then the middle of top and they kind of spread back…

Dr. Janice Townsend: Yeah, they do.

Dr. Mike Patrick: From the front. And there's a pretty big range though, right? Like if one kid has their first tooth at 6 months, there may be a cousin that then doesn't get their tooth until closer to 12 months, right?

Dr. Janice Townsend: Yeah. So six months is sort of the middle of the dart board but kids are all over the map. We actually have babies that are born with teeth sometimes. That's uncommon but it happens. But usually the variation, probably the earliest is around three to four months but I have seen some infant up to age one year. 

One thing to keep in mind, that premature infants may have delayed eruption and there some other medical conditions associated with delayed eruption.


Dr. Mike Patrick: When  should parents worry that their child doesn't have a tooth yet? So if they're coming for the 12 month checkup, should their pediatrician say, "Well, let's give it to 15 months." And then, when do you start to worry and want someone to check things out.

Dr. Janice Townsend: We recommend that every child see a dentist by age one. So I would say no later than age one especially if the teeth aren't there. And if parents want to  come in a little bit earlier maybe for a nine-month's check, it would be okay. Now, most dentist are probably going to take it their own medical history, make sure that maybe there's no medical condition that could have been overlooked. And then they're probably just going to tell us to watch and wait for awhile.

Dr. Mike Patrick: Yeah. And I have to say my own experience in doing this over 20 years, I just had a handful of kids with rare genetic diseases like ectodermal dysplasia, for example, where you can have significantly delayed onset of tooth eruption and then missing teeth or malformed teeth.  But we can still say with some reassurance, even at 12 months, just give it a little longer because in the vast majority of cases, that is the case.


Dr. Janice Townsend: That is the case. And the other things is there's not really anything you're going to do about it. So we wouldn't want to subject the baby to unnecessary X-rays or tests when there's no real answer for it. 

Dr. Mike Patrick: What are the signs and symptoms that go along with infant teething. I mean, we have all kinds of ideas in mind, but just as a pediatric dentist, what do you think teething really causes?

Dr. Janice Townsend: Well, number one is drooling. When you see a lot of drool on that little bib or on that little shirt, you know it's about time. Drooling is very normal. In studies, where they've taken a really accurate temperature babies in daycare, they can see maybe a half-a-point difference. 

So those are really the things that are commonly seen. Unfortunately, we can have some really sick children out there and people blame it on teething. So if there's a fever over 101 degrees, that is not normal teething. They need to see a doctor right away. Any kind of vomiting, diarrhea, again, that's not normal with teething. And it could be that the child is sick and it just happens to coincide with the time the teeth are coming in. 


So normal, lots of spill, lots of drool, normal little bit of fuzziness, maybe a slight temperature elevation. Anything else, they need to go to the pediatrician.

Dr. Mike Patrick: And definitely for 101 or higher. But the technical definition of a fever is 100.4 and, in your experience, even that, I mean, they might be 99 or they might had a 100 with teething. But they're not really going to have a true, by definition, fever that will be caused from teething. The fuzziness, you said a little bit of fuzziness. What about babies who are really fuzzy, is that their teeth?


Dr. Janice Townsend: Not necessarily. Again, you would want to rule out some other factor to make sure there is not something causing pain or other forms of discomfort. 

So again, I would still say, I don't know if there's a fuzziness scale but still on the little bit of side, a child crying uncontrollably and just can't be pacified in any way, that's probably not the teething.

Dr. Mike Patrick: And I love having a pediatric dentist here to talk about this because as I think back to the advice that I've given parents, I hope this is right, so correct me if I'm wrong. But my idea is that when you have kids who are two years old and getting the next set of molars. And then they get another set of molars like when they're four, five years old, then they can talk to you. And generally they aren't telling you, "Oh, this really hurts a lot," and asking for pain medicine or to go see the doctor. 

So we can expect that those same kind of symptoms they're experiencing when they're teething when they're older is probably similar to what they were experiencing when they were babies. Is that spot on?

Dr. Janice Townsend: Absolutely.

Dr. Mike Patrick: Good. So let's say a baby is a little fuzzy and you think they're having a little bit of discomfort. What can you do to help them?


Dr. Janice Townsend: Well, cold. Cold is something that helps dramatically. If you're going to use the teething ring, you can put it in the refrigerator to make it cold. We do want you to use a firm rubber teething ring. Any of the ones that have liquid in it, there's a chance that they could puncture that liquid and swallow it. So nothing with little pieces, a firm rubber teething ring. 

Cold food also feel really good, so some pudding or some yogurt that they can just sort of almost put in their gums to sooth helps. Wiping the gums up with the cool wash rag and if you want to put it in the freezer for a little while to make it cold, all of those are good therapies.

Now, there is one concern and that's the traditional teething gels that probably you and I had when we were little. Those are no longer recommended. So they have a drug called benzocaine in them, and benzocaine has been associated with a rare but very serious medical condition called hemoglobinemia. So in these children, there's been case reports of the parents using the teething gel, then having the reaction and what it can cause. It causes structure of the blood to change so that it's no longer carrying oxygen. 


So again, this is a dangerous medical condition. It's hemoglobinemia and that's with benzocaine. So the teething gels in general really don't work and can be dangerous, so parents should be avoid those.

Dr. Mike Patrick: Absolutely. The other chemical to avoid is belladonna which is a plant poison. It's also known as deadly night shade and there are some products that have a tiny amount of belladonna in them and are marketed as kind of herbal remedies, teething tablets. And you would not recommend those either, correct?

Dr. Janice Townsend: Not at all. Dear, I don't think I was aware of this.

Dr. Mike Patrick: Yeah, yeah, no, they are out there. 

Dr. Janice Townsend: All right. 

Dr. Mike Patrick: And I won't mention a brand name but if you do Google search for infant teething in belladonna, you will find it pretty easily.


And then you mention cool, what about frozen? Kind of like a popsicle or and hopefully, this is okay, we used to take wet wash rag and then put that in the freezer. So it get like the little ice chips on it. And then, our kids would sort of suck on that and you get that texture, kind of feels good on their gums. Is that safe to do? 

Dr. Janice Townsend: Definitely.

Dr. Mike Patrick: And then, if they're an older kid and you think they're a little fuzzy, you could give them some acetaminophen or ibuprofen and just see if that helps. Of course, it could be pain from something helps. But if they're consistently fuzzy and very fuzzy, see your child's medical provider to make sure there's not something else going on because we don't expect severe fuzziness with teething.

Dr. Janice Townsend: Yes.

Dr. Mike Patrick: And then one other thing we should mention, teething necklaces are kind of a big deal thing right now.

Dr. Janice Townsend: They are.

Dr. Mike Patrick: Are those safe?

Dr. Janice Townsend: Probably not. 

Dr. Mike Patrick: Okay.
Dr. Janice Townsend: Okay, any time that there is something that has small beads that could be broken, that could come off, it could be an aspiration risk. So generally, when you think about the risk versus the benefit, I would stick with the firm rubber teething ring.


Dr. Mike Patrick: Yeah, absolutely. And the other thing is there's strangulation hazard, correct?

Dr. Janice Townsend: That is right.

Dr. Mike Patrick: I mean, if it's around their neck and you look away for just a few seconds and they can have it twisted or caught on something. And there have been babies who have strangulated themselves with teething necklaces. 

And then you share something about that on social media and parents will say, "Well, I wear the teething necklace and hold the kids and they're chewing on it," Again, it's a big piece of solid plastic that's similar to the solid teething ring and you're right there with them. And this is just the kind of stuff that comes up on social media.

Dr. Janice Townsend: Yeah. I just wouldn't recommend it. And again, it's becoming a trend but…

Dr. Mike Patrick: There are babies who have been hurt with these things.

Dr. Janice Townsend: They are, they are.


Dr. Mike Patrick: So once teething get started, when can we expect it to end?

Dr. Janice Townsend: It doesn't end. We always joke whenever. So we have six-year-olds that will come in with pain and they're truly teething again. They're getting their permanent six-year molars, but just kidding. In the primary teeth, usually before the age of three, all of the teeth are in. And again, in my experience, usually the teething for those back molars isn't as uncomfortable as some of those early teeth.

Dr. Mike Patrick: And then, once the teeth do come in… Actually, even before then, so is there something that parents ought to do even before the teeth first erupt just to help out with oral care.

Dr. Janice Townsend: Yeah, so before the teeth erupt, you can use a wash rag. Or you could use a brush if you want and just gently clean the gums, wipe away any residue. Get the kids used to having something in their mouths and then once the teeth erupt, we do recommend brushing twice a day.


Dr. Mike Patrick: And how often? Should that be twice a day as well when you just do the gum care?

Dr. Janice Townsend: Yeah. I mean, again, it's more just about overall hygiene, like clean your face, wash your gums, all of that.

Dr. Mike Patrick: So when the first tooth erupts, then absolutely at that point, you want to be brushing that tooth with the baby size toothbrush and soft bristles. And what do you use at that point?

Dr. Janice Townsend: Our guidelines, our American Academy of Pediatric Dentistry guidelines recommend fluoride toothpaste, so a children's toothpaste that has fluoride. The key to fluoride toothpaste is the amount. They really just want a little smear. Some people use the term a grain of rice but a very small amount is all that's needed to keep the teeth clean and the fluoride will help make the teeth strong.

Dr. Mike Patrick: And how long should you brush?

Dr. Janice Townsend: Well, that one tooth.


Dr. Janice Townsend: We always say brush two minutes twice a day. I think if you brush that one tooth for two minutes, that might be a little overkill.



Dr. Mike Patrick: And you can also brush some of the gum if you're brushing at the same spot. Then, they are going to be fuzzy, right?

Dr. Janice Townsend: I think reasonably as much as needed to get the teeth clean.

Dr. Mike Patrick: And then you also read online about the pea size amount but we're talking about older kids, not babies, right?

Dr. Janice Townsend: Pea size is older kids probably closer to three and four. And again, this is all based on spitting. We want the toothpaste to come in contact with the tooth to make it strong but we don't want kids swallowing a lot of toothpaste. 

So again, when they're very little and we pretty much think there's a high change of them swallowing, we're going to use the smear or the rice. And then when they're older and can start to spit, then we're going to use the pea size amount.

Dr. Mike Patrick: And then, the other thing with brushing, so we get fluoride on the tooth and we'll talk more about exactly how fluoride works and how it makes teeth stronger, but you're also brushing and people heard of plaque and bacteria. Brushing also helps to discourage the formation of that, correct?


Dr. Janice Townsend: Yeah. And so it's all interrelated. So basically, in our mouths, we all have bacteria. We have bacteria that cause cavities. We have bacteria that cause gingival disease. And by brushing, one way of saying it, we're sort of knocking down the house they live in. We're getting rid of that plaque which is where they live and it helps reduce the amount of bacteria.

So one, it's going to help prevent cavities but, two, it's also going to make the gingiva or the gums healthier.

Dr. Mike Patrick: And twice a day. And one of them should be after the last that they eat before they go to bed, correct?

Dr. Janice Townsend: Yes. And that's the most important time. Unfortunately, it's the one that get skipped. People brush in the morning so they'll be fresh for the day, but for preventing cavities, the most important time is right before you go to bed. So those bacteria that we talked about that live on the teeth, what they eat is sugar or carbohydrates.


So if you go to bed with lots of sugar, carbohydrates on their teeth, again, what I'm explaining to children, they can have a party in your mouth all night long and you're bringing the food. So we want to get that all taken off before we go to bed. Bedtime's especially critical because at night, you don't make as much saliva. We all wake up with that really dry mouth. And without that saliva, it's an even bigger opportunity for plaque to spread.

Dr. Mike Patrick: When should babies see a dentist for the first time? You had mentioned definitely by a year, but is there instance when you'd see them sooner?

Dr. Janice Townsend: Well, we recommend age one as the latest point, as you said. The recommendation to come in sooner may be if patients have medical conditions that can affect their teeth, maybe we're going to want to see them earlier. If there's a family history of all the kids in the family having cavities at a very young age, if they want to bring their patient in before the teeth erupt.


One of the most important things we do during that visit is education. We do a lot of education showing parents how to brush, talking about what foods and drinks to avoid. So if this is a first baby and this is an area you don't really feel like you know as much about, you may even want to come in before the teeth erupt so you make sure that the baby is on the right track.

Dr. Mike Patrick: So definitely, by 12 months but can be sooner especially if their teeth are erupting and you have questions and you want someone to take a peek.

And then, who should they see? So you're a pediatric dentist, so you had additional training after regular dental school to really specialize in children's teeth. Is it necessary for them to see a pediatric dentist?

Dr. Janice Townsend: I think that there are general dentists who aren't pediatric dentists who are still very knowledgeable about infant oral health. And one of the thing is geography, not every town has a pediatric dentist. So if you have a dentist, pediatric dentist, or general dentist that is knowledgeable and willing to see babies, you can go to that dentist.


Now, if there are problems with the teeth forming or the child has cavities at a very early age, almost always they're going to refer you to a pediatric dentist.

Dr. Mike Patrick: Yeah. And this may be something while you're expecting, you probably have a dental visit at some point during that nine-month period. Hopefully, you do. And you could just raise the conversation, like, "Do you see kids? Are you comfortable with kids?" Would you rather see a pediatric dentist to begin with? And that may give you some sense of the expertise of the person who's taking care of mom and dad's teeth.

Dr. Janice Townsend: Yeah. And that raises two very good points. Sometimes, women feel discouraged from seeing a dentist while they're pregnant. That is the time that they should see a dentist because we know that the oral health of the mom is very closely related to the oral health of the baby, so excellent point. 

And then, second, I think sometimes because your dentist doesn't see a child until age three, parents get the perception that no children are supposed to go to age three.  So even if your dentist says, "Oh, we don't see children to age three," then that's a sign that maybe you need to look for a different dentist or pediatric dentist.


Dr. Mike Patrick: And then, once you start establishing care with the dentist for infants, how often should you go?

Dr. Janice Townsend: Well, routinely, patients go every six months. And again, this can be changed based on caries risks. So kids that are really prone to cavities for a number of conditions may need to go as often as every three months. There are other children that are very low caries risk and if that's a discussion you have with your dentist, they may say up to one year. But the general recall interval is six months.

Dr. Mike Patrick: And when you say caries, that's another word for cavities, right? 

Dr. Janice Townsend: That's the fancy word for cavities.

Dr. Mike Patrick: But it's the same thing?

Dr. Janice Townsend: It's the same thing. Well, actually, caries is the disease process, the cavity is the hole on the tooth. So you may have the disease process but it may not be a hole yet. That's why we'd like to see the kids really early because sometimes we can intervene and keep it from turning into a cavity. If you have a cavity, you have  caries.


Dr. Mike Patrick: So the cavity process, so you talked about the plaque and the bacteria having a party on the teeth and they are consuming sugars and then making acids. And then, the acids basically dissolve the tooth? Is that how that happens?

Dr. Janice Townsend: That's exactly right. So again, there's a special sauce to it. You've got to have a tooth. You've got to have bacteria and then the bacteria have to have something to eat. 

So we want our kids to have teeth, so we can't control that. We all have bacteria. And again, there are science looking at can we have a vaccine? And really, our microbial environment is just too complex for that, so we're going to have the bacteria. 

So the only thing we can really control is what we feed them and then how long we let them stay on the teeth. So that's why diet and oral hygiene are two of the critical factors. They do destroy teeth through acid, through demineralization and that's where our fluoride comes in because it can help reverse that demineralization.


Dr. Mike Patrick: And then once the hole gets to the point where it's reached really the center of the tooth, there's a nerve there. And so that's why you get the pain and the sensitivity once it eats all the way through, basically.

Dr. Janice Townsend: Yes. And unfortunately, there's this perception out there in lots of communities that baby teeth aren't important. And baby teeth are important. We need them for our kids to be able to eat healthy foods. We want them to be able to learn speech and be able to make all the sounds. Kids like the way they look and they like that pretty smile.

And then, baby teeth also do help save space for the permanent teeth. So parents may think they're saving some money by not getting the baby teeth fixed. And in fact, they can really be making it hard to have space for the permanent teeth and may start of have to pay the piper down the road. 

So primary teeth are important. And then lastly, like you said, we don't want kids to have pain and infection related to teeth.


Dr. Mike Patrick: Yeah, because the next thing is the bacteria go down the hole into the center and can cause an abscess. 

And you mentioned getting rid of the mouth bacteria. If you get rid of those, then yeast are going to come and start growing and you have thrush, right?

Dr. Janice Townsend: Exactly.

Dr. Mike Patrick: Something is going to grow in there?

Dr. Janice Townsend: Yeah.

Dr. Mike Patrick: Okay. So once you do have a cavity… You know what, actually, before we even get there, so my daughter had a bunch of cavities with her baby teeth. My son didn't have a single one, same diet, same tooth care. Is there a makeup of teeth that is somehow more resistant to the caries than others? Is that possible? I've never had a cavity and my wife has had a ton of cavities.


Dr. Janice Townsend: To Tiffany, then what I would  say is that…

Dr. Mike Patrick: I brush better.

Dr. Janice Townsend: The one got your wife's bacteria.

Dr. Mike Patrick: Yeah, her teeth, yeah.

Dr. Janice Townsend: Again, this is sort of cutting edge of science, people looking at the composition of teeth. Or some teeth, do they have more pores, things like that. But there's just not enough science out there to say that that's the case or not.

And really, it usually tracks back to diet and usually once we start really looking at who's watching them, where they're staying at all points in the day, when we see the cavities, we can usually find juice is what we almost always find. 

So sometimes it's a change in the daycare center. Sometimes, one child has teacher who is really good about having the children drink water. The other one, juice all the time. There's a grandparent, there's a babysitter. But we can almost always track it back to liquid sugar.


Dr. Mike Patrick: Now, I think about it, maybe she did have more. She was our first. And so, maybe you do some diet changes with the second one, that's possible. So maybe it's not the fault of her teeth, maybe it was our fault as parents.

Dr. Janice Townsend: Well, we do hear and we do take it seriously. And again, it's not about who's fault, it's not about blaming. It happens, it happens. But the main focus is how can we keep the cavities from getting worse, how can we fix them, and then how can we keep them cavity free in their permanent teeth.

Dr. Mike Patrick: Once you do have a cavity, how do you then go about addressing that in baby teeth?

Dr. Janice Townsend: Again, this is where that difference between what you pointed out, caries and cavities is very important. Because if the caries, if there's demineralization or just a white spot, what we can do is we can either put fluoride varnish, which can help make that softer enamel hard again. Or there's a new product, silver diamine fluoride which can also arrest that decay. 

So that's why we like the kids early because if they have the start of a cavity, we can fix it.


Even if it's a hole, if it's a very small hole, sometimes we can do what's called interim restorative therapy and with this, it's not traumatic. We let the babies lay on the parent's lap. We don't have to numb them up. We use either some hand instruments or really slowly rotating burr to just take out the top part of the cavity. And we have some new filling materials that will stay, seal it up and can also release fluoride and make the cavity hard again.

So early is better. Whenever we see the kids later, when the cavity is pretty big, then we're usually looking at some kind of restoration. I got asked all the time why do we still use stainless old crowns or the silver caps and the answer is because they work. They work really well.

And the last thing we want to do is to do something to a primary tooth that just needs to be redone again in one year. What we try to do is match the type of restoration or filling to the life of that baby tooth.


Dr. Mike Patrick: And do you sometimes have to pull the tooth?

Dr. Janice Townsend: Yeah, unfortunately. And it's …

Dr. Mike Patrick: Is that when there's just not enough structure left to do able to do anything with it?

Dr. Janice Townsend: Not enough structure. Certain teeth, we can actually treat the nerve and do a baby root canal. Other teeth, if they're that badly damaged, then we're going to go ahead and remove it and not try the baby root canal.

One thing parents need to remember is even though they can see the baby teeth in the mouth, the permanent teeth are there and they're forming right underneath these baby teeth. So if there's a very bad abscess to a baby tooth, it can actually cause damage to the enamel of the permanent tooth. 

So the big example is the front teeth. If they have abscesses, we want to remove those to make sure that there's not spots on the permanent teeth.


Dr. Mike Patrick: Right. And then we talked about in terms of cavity prevention because it's better to prevent this whole process and not have to restore teeth, right? It's better to prevent in the first place.

Dr. Janice Townsend: Absolutely. 

Dr. Mike Patrick: And we've talked a couple of ways that you can do that, proper gum and tooth care which we described, and fluoride in the toothpaste. And we'll talk more about fluoride here in a minute. But there are other things that parent should watch for, the bottles at night? They shouldn't have sugar in their bottle at night, right?

Dr. Janice Townsend: Yeah. 

Dr. Mike Patrick: And that includes milk.

Dr. Janice Townsend: And that goes back to diet, so yes. Any bottle at night should only have water. And one of the things that we've learned over the years is that it's not necessarily the total amount of sugar that a child gets, it's how often they get the sugar. Every time you have anything with sugar on your teeth, juice, milk, you're going to be in a cavity zone for about 20 minutes, where your body is making that acid that will sort of destroy the teeth.


You've got a kid, they like candy. If they have their bag of Skittles and they ate all their candy at once and then don't eat it anymore, they'll probably be in that cavity zones for about 20, 30 minutes.

The kids we worry about are the ones that have the sippy cup. They take a sip of the juice, in the cavity zone 20 minutes, put it down, go play, come back, take a sip of juice, cavity zone 20 minutes. And once we start educating families about that, many of them realize it's no surprise their children have cavities because they spent their entire day in the cavity zone with their sippy cup. So anything like sippy cup, a bottle, needs to have water only.

Dr. Mike Patrick: And there's other medical reasons why you may not want to have juice all day anyway as we think about obesity and the amount of calories that kids get. And water is going to be a better drink for most kids. I mean, you have to look at their growth curve and individualize that advice to some degree.


But certainly, if you're going to do juice, it's better to drink your juice and then move on rather than to have it available to sip on throughout the day. And then, that's also a reason why a bottle of milk at night is bad because they're kind of sipping on it intermittently and it just sits there on their teeth.

Dr. Janice Townsend: It sits there on their teeth. And like we talked about it, when your mouth is dry, you don't have that saliva to help protect your teeth. And yes, it's a perfect storm. That's why we have kids sometimes at the age of one who already have cavities.

Dr. Mike Patrick: Let's talk a little bit more about fluoride. And exactly what does fluoride do? How does it work? How does it protect teeth?

Dr. Janice Townsend: Well, fluoride is something that scientists sort of stumbled upon because there were certain communities that didn't have cavities back in the 40s when the rest of America had a lot of cavities. So what it is, it is a mineral, and whenever the teeth are attacked by bacteria that make acid, we used the term demineralization. And basically, it's taking the minerals out of the teeth.


What fluoride can do is it can remineralize or help add the mineral back into teeth. And actually the teeth that were remineralized with fluoride have a different composition, and it makes them even stronger. So that's why we use it. One, it helps repair the damage that acid and bacteria caused and it makes the teeth even stronger than they are in their normal state.

Dr. Mike Patrick: So you're losing a little bit of calcium, but you're putting in fluoride but not completely.

Dr. Janice Townsend: You're putting in the calcium and fluoride combination, which is even stronger.

Dr. Mike Patrick: Calcium comes from diet?

Dr. Janice Townsend: Yeah.

Dr. Mike Patrick: Okay. When the fluoride gets incorporated into the tooth, it takes more calcium with it?

Dr. Janice Townsend: Yes.

Dr. Mike Patrick: And makes it stronger.

Dr. Janice Townsend: It makes it stronger.

Dr. Mike Patrick: Gotcha. Now, you can also have too much fluoride though? We don't want too much fluoride in the teeth. What happens if that occurs?

Dr. Janice Townsend: Again, that's where sort of "This is the Goldilocks." No fluoride is bad, too much fluoride is bad and we want to be in the middle. When children get too much fluoride, then it can cause something called fluorosis. 


The vast majority of fluorosis is very minor and what it can look like is a little white speckle on the teeth. So the teeth have some little white characterization, still isn't aesthetically anything bad.

However, if kids are getting lots of fluoride, so maybe mom asked for a fluoride tablet prescription from pediatrician, is also letting child put their own toothpaste on the toothbrush and is eating a lot of that. That combination of all these sources of fluoride can cause more moderate fluorosis. 

Again, it's very rare in practice for us to see moderate fluorosis. We usually see it in areas of the world where they just have way too much fluoride in their drinking water. In America, we'll see some mild fluorosis with kids who get too much fluoride toothpaste and the combination of that and the fluoride tablets and maybe fluoride in the water, but it's generally very mild.


Dr. Mike Patrick: And when it's fluoride in the water, it's usually well water that has natural fluoride, not communities that are adding too much fluoride?

Dr. Janice Townsend: No, communities add a minimal amount of fluoride. Again, just to optimize the effects without causing fluorosis.

Dr. Mike Patrick: I'm a history buff and so folks who listen to the program regularly, I'm always looking up this sort of thing. And I came across, there was something called, back in the late 1800s and early 1900s, Colorado Brown Stain. And so in Colorado Springs, just the people there had brown teeth but no one really knew why. But they also didn't have cavities. 

And then, they trace it back to what we would call now too much fluoride in the water. And then, that was happening in other communities as well. And so as you said, we kind of stumbled upon that fluoride can do this for us.


But it's really been probably one of the most successful public health efforts then, adding fluoride to community water. When you look at the number of cavities that folks had before this discovery and after, it has really made a lot of difference in many, many people's lives, right?

Dr. Janice Townsend: Yeah, it has. And I've never understood exactly where so much of the opposition to fluoride can come from. But it's really sad because sometimes, you can get some very outspoken people in the community spread misinformation. And usually, the people who suffer the worst are people who don't have enough money to go to the dentist regularly and their children.

Dr. Mike Patrick: Absolutely. And parents can be an advocate then in your own community if this does come up on the ballot to add fluoride to the water, and there is that voice out there that is spreading these misconceptions. Parents can take to social media and advocate for adding fluoride in the water in their community just by raising their voice and putting evidence-based information, like we're providing here, out to their fellow community members.


Dr. Janice Townsend: Whenever we talk about fake news, fluoride was the original. But dentists, we went in this to help people. We want to help children. We want to keep them cavity free. If there's anything that gain from it, it's with us. It's sort of takes away our business. But all dentists, we would prefer not to have to treat children, especially a very young children with cavities. And we want to give families all the tools to help their children be cavity-free.

Dr. Mike Patrick: So instead of big pharma, it's big water. Because they're giving you money to put the fluoride in the water, right? No, no, no.

Dr. Janice Townsend: I didn't get that joke.


Dr. Mike Patrick: So one of the things that we've said here is that there can be too much fluoride in water. If parents are using well water, it's a good idea to have that water tested, right? And your local health department can do that, not only for what's the fluoride level but then also what's the bacterial load in your well water. And does that need to be addressed, which can be a safety issue with young infants. 

So if the well water does have too much, then what's a parent to do?


Dr. Janice Townsend: Bottled water.

Dr. Mike Patrick: And there is bottled water that folks can get that has fluoride in it, right?

Dr. Janice Townsend: Yes, they can. And different types of spring water can have fluoride. The baby or the nursery water can have fluoride as well. And again, I rarely hear that with parents getting tested, their well is tested and finding out it's too high. Usually it's too low. 

But it's a very good point that sometimes, people have well water and they'll just assume that there's no fluoride in it and tell maybe pediatricians mistakenly that they're not getting any fluoride in their water when they don't know. So before asking for a fluoride supplement or fluoride tablets, the well water testing is critical.


Dr. Mike Patrick: And if you call your local health department, they do often know geography-wise where there is too much fluoride. For instance, when I was in a private practice in Springfield, Ohio, the eastern part of Clark County, so around South Vienna, south Charleston kind of area, they did have very high natural fluoride. And we actually saw cases of fluorosis in our patient population. 

I mean, it's out there but the biggest thing is just don't use your well water and just buy the nursery water instead. You can even buy it by the big, the 5 galloon dispensers with a little bit of safe amount of fluoride in it.

So then, other than the normal amount of fluoride in the water, either through a nursery water or through a community that has fluoride in the water, and then brushing, is there a reason to do fluoride supplements beyond that? So like the fluoride drops or the fluoride tablets, what do you think? Is there ever a reason to use those, do you think?


Dr. Janice Townsend: I think these can be a little controversial. In my opinion though, the real benefit from fluoride is when it comes in the teeth, not when it's swallowed. In my experience, usually the families who remember to take a tablet every day or put drops in their water every day are also the families who remember to brush their child's teeth every day. And people can inadvertently get in that scenario where they're using too much fluoride. So the topical fluoride, drinking the fluoridated water, that would be my recommendation.

Dr. Mike Patrick: And then the fluoride varnish, sometimes pediatricians put those on. What do you think of that?

Dr. Janice Townsend: We love it. So that's our preferred way to get fluoride. Fluoride needs to come in contact with the teeth for about four minutes to have an impact. And you can imagine whenever we were seeing babies before fluoride varnish was invented, being able to keep the fluoride in contact with the teeth for that long, we just couldn't do it. So fluoride varnish has been a wonderful way to apply fluoride to infant's teeth for the maximum benefit.


And we are supportive of different providers providing it because we know that even though we would like all kids to get to see a dentist by age one, it's just not a reality for some families.

Now if you do get a fluoride varnish application at a medical setting and you have a dentist appointment the following week, you may want to check in with your dentist and make a decision together about if it would really be beneficial at that point or not.

Dr. Mike Patrick: So it is okay to do the fluoride varnish with the medical provider, and fluoride in the water, and brushing with the fluoride toothpaste, that's not going to be too much. Or you're most likely get into trouble with too much fluoride as if you're also doing a supplement or if the well water has too much fluoride in it? I've been trying to sum it up.


Dr. Janice Townsend: Very good, yes. Or if the parents are letting the children control the amount of toothpaste.

Dr. Mike Patrick: So if  you're getting more than grain-of-rice size for under three and pea size over three?

Dr. Janice Townsend: Yeah. And again, going back to the varnish, if you've ever had it, it is incredibly sticky. And that sticky is the good thing and that means the babies aren't getting too much into their system. They're not swallowing too much. Most of it is sticking to the teeth.

Dr. Mike Patrick: A lot of adults get this as well. I mean, when I go to my dentist every six months, they put fluoride varnish on. So it's a good thing all around, baby teeth and adult teeth.

Dr. Janice Townsend: Definitely. And then, once we get through this baby ages where kids can spit out toothpaste, we might even consider prescribing higher amount of fluoride for kids that are in braces, for kids that have lots of cavities. Maybe for a patient that's had to have head and neck radiation and doesn't even make enough saliva.

Dr. Mike Patrick: Let's move on and this still involves teeth a little bit. What about pacifiers and thumbsucking? What do you think as a dentist?


Dr. Janice Townsend: Well, they're not our favorite. But no, in young infant, this is natural. It's very natural to self-suit. We don't get too worried about it.

And then, about age two though, it's time to make that transition away. As far as pacifiers versus thumbs, I haven't had a lot of luck getting rid of thumbs. They have to go with this. Sometimes it can be easier to break the habit if there's a pacifier. And the pacifier some sort of tactics is maybe there's a new baby in the family, a little cousin and you go to their house and they get the pacifier now. Sometimes you get to go to the store and you get to trade in your pacifier for a present because you're a big kid now. 

So that's my only recommendation pacifier versus thumbs. It's much easier to break the habit. Persistent habits that go definitely beyond the age of three can have some lasting effects on the teeth.


So things that you can see are that the front upper teeth are really flared out and this doesn't look very good. The kid, you can look at and say, "You're a thumbsucker." And also it can make the teeth a lot more prone to trauma because they're just sticking out there. And if the kids fall, the teeth are going to go out with it.

So habits are normal in infants, should start to tape her off at around the age two, and should not last before age three.

Dr. Mike Patrick: That is a great advice. So, no thumbsucking, no pacifiers, sometime between two and three. Try to get rid of it closer to age two though?

Dr. Janice Townsend: And you're going to have a lot easier time getting rid of the pacifier than the thumbsucking.

Dr. Mike Patrick: And then one more question. Well, actually, speaking of thumbsucking, do you have any hints on how to, like the pacifier then you can trade it in. You know, they got the stuff you can put on the thumb that doesn't taste very good or put a sock on the night time. Any other advice for that?

Dr. Janice Townsend: It is a challenge. Thumbsucking is a challenge. And with the very young children, sometimes they just don't understand. So you almost have to wait for them to get a little older.


Things that work well are positive reinforcements. So reminder calendars if they can go a whole day without sucking their thumb, they get a sticker. If they get five stickers, maybe they get to go spend the night at grandma's house.

One of the cruel ways, give to a kid little recorders and every time they suck their thumb, they have to give the recorder back.


Dr. Janice Townsend: Sometimes, what I see there was parents sort of nagging because they're sucking their thumb. And sometimes, kids can use it as a way to get a bit of attention. If there's maybe a younger sibling that's getting a lot of attention, that five-year-old will start sucking their thumb again knowing every time mom sees them suck their thumb, they're going to give them some attention. So sometimes, ignoring can even be one of the better ways to address it.

Dr. Mike Patrick: Great advice. And then sometimes kids will have a little flap of gum that separates the two front teeth up on top and make a space there. Is that something to worry about?


Dr. Janice Townsend: No. That's again part of normal development and we've actually studied this. So as you grow older, that little flap of gum almost always grows up with it. And that's why if you look at your own gum, most of us did not have any kind of medical procedure to get rid of it and yet that flap or that frenum is gone or really half. It's part of normal development.

Some people have said that if you go in there and cut it early, the kids won't have a gap in their teeth. And that really doesn't make any sense because usually they're just cutting the gap where it attaches to the top of the gum. They're not actually dissecting it through the teeth. And finally, if you did dissect through the teeth, you're going to leave some scar tissue. 

So the recommendation is to wait for all the permanent teeth to erupt. See an orthodontist, if you need to, to close the space. And while they're in the orthodontist, that's the time that the orthodontist may work with you to decide if it's time to cut that gum.


Dr. Mike Patrick: But babies and toddlers, this is something you just watch. You don't do anything with it. 

Dr. Janice Townsend: It is fine. And again, this is something that social media, it's become a very trendy procedure and kids have done very well for many millennia without getting this done. And we just worry about exposing very young children unnecessary medical procedures. So the literature's just not out there to support this at this time, and we don't recommend it. 

Dr. Mike Patrick: And then sometimes, they fall down and that little frenulum gets cut. And if it does, you just leave it still, right?

Dr. Janice Townsend: Exactly.

Dr. Mike Patrick: You don't fix that.

Dr. Janice Townsend: They do their own.

Dr. Mike Patrick: You don't fix that. You don't fix it back and then take it out later.

Dr. Janice Townsend: Oh yeah, exactly.

Dr. Mike Patrick: So before we go, just give us an idea of the services that you provide and just in general pediatric industry here at Nationwide Children's. I have to say I have practice in some different locations around the country here in Ohio, also down in Florida, and the support that we get from our pediatric dentists here in Central Ohio is topnotch. And just tell us a little bit about what you do.


Dr. Janice Townsend: Well, I agree totally. We're very proud of our program here. And it is one of the premiere pediatric dental departments in the country. Children's Hospital is very generous to our department and many hospitals don't have dentistry, so we're very fortunate. We  have a 30-chair clinic in our Livingston Avenue clinic building. The Lock is what a lot of people call it. 

So we have a 30-chair clinic. We see new patients. We see babies. We see teenagers of all ages. And we provide ongoing care and also emergency care to children that are in pain. 

We also have an after-hours clinic. So that is on weekday evenings and Saturday mornings. And this is more for our teenagers and are adolescents who maybe can't miss a lot of school. So our well-behaved teenagers adolescents, this is a time they can go to the dentist with a little less impact on parents' work schedule and their school schedule.


In addition to having those dental clinics open, we have a special clinic where we do sedation for the children that are young or just very scared about going to the dentist. And then, we have a dental surgery center for our children that unfortunately have to be put all the way to sleep to get their teeth fixed.

Dr. Mike Patrick: And we'll put a link to pediatric dentistry here at Nationwide Children's Hospital in the Show Notes for this Episode 423, so folks can find you and get connected very easily.

If you're in another part of the country and you want to find a pediatric dentist in your necks of the woods, I'll also put a link to American Academy of Pediatric Dentistry. At their site, you can do a search and find where certified pediatric dentists are in every state of the country. So folks can find you easily.

And then we'll have lots more links in the Show Notes. We have a series called Helping Hands here at our hospital which are just patient educational material. We have one on baby bottle tooth decay, teeth and gum care for infants and toddlers. We'll put both of those in the Show Notes.


And then, the American Dental Association has a great website called Mouth Healthy. And I'll put the teething article from them. And then, My Children's Teeth from the American Academy Pediatric Dentistry. And the American Academy of Pediatrics has a great resource called Baby's First Tooth: 7 Facts Parents Should Know. I'll put all of these resources in the Show Notes for this Episode 423 over at

So Dr. Janice Townsend, chief of pediatric dentistry here at Nationwide Children's Hospital, once again, thanks so much for stopping by.

Dr. Janice Townsend: Thank you.



Dr. Mike Patrick: We are back with just enough times to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. I really do appreciate that. Also thanks to our guest this week, Dr. Janice Townsend, chief of pediatric dentistry here at Nationwide Children's.

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Announcer 2: This program is a production of Nationwide Children's. Thanks for listening. We'll see you next time on PediaCast.

5 thoughts on “Infant Teething and Toddler Tooth Care – PediaCast 423

  1. This had a lot of good information. But, I would like someone to address the practice of adults putting the child’s pacifier into their own mouths and feeding the babies from the same utensil that they use. I see this frequently and I’m concerned about the adult’s bacteria being transferred to the child.
    Thank you.

    • Hi Janet. Great question! We covered this to some extent in PediaCast 255. Transferring bacteria from a parent’s mouth to a baby’s mouth may actually protect from future development of some allergies in the child! A baby’s mouth has to get colonized with bacteria from somewhere, and it would appear colonization with a parent’s collection of microorganisms is a good thing. Of course, this is one small study and more research is needed, but as long as mom or dad aren’t actively sick at the time, i don’t think there’s a problem with sharing “good bacteria” by way of pacifiers or spoons. Hope that helps! ~ Dr MikeĀ 

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