Tooth Care for Kids and Teens – PediaCast 439
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- Dr Janice Townsend returns to the PediaCast Studio as we conclude our dental trilogy. This week we explore tooth care for kids and teens, including brushing and flossing (of course), fluoride, cavities, fillings, root canals, crowns, implants, dental sealants and teeth whitening. Previous installments include Baby Tooth Care and Dental Injuries. You can catch the entire series on SoundCloud. We hope you can join us!
- Tooth Care for Kids and Teens
- Brushing and Flossing
- Cavity Prevention and Treatment
- Fillings, Root Canals, Crowns and Implants
- Dental Sealants
- Teeth Whitening
Announcer 1: This is PediaCast.
Announcer 1: 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're in Columbus, Ohio.
It is Episode 439 for August 15th, 2019. We're calling this one "Toothcare for Kids and Teens". I want to welcome all of you to the program.
So 2019 has been the year of the tooth on PediaCast. This is going to be our third episode on dental matters with our resident expert dentist, Dr. Janice Townsend.
I'll begin back in February when we covered infant teething and toddler toothcare. That was Episode 423. Then, we continued the story in April as we considered dental injuries and emergency toothcare in Episode 429. Our final installment of the series, at least for this year, explores toothcare for older kids, so beyond the toddler years and teenagers.
And truth be told, all of these will be applicable to parents as well as we consider our own dental hygiene. So we'll cover brushing and flossing in considerable detail. And yes, there are very important details to consider -- what type of toothbrush is best. There are so many options, right? Soft and hard bristles, small and large heads, motorized varieties, hyper-vibrating options.
Then there's toothpaste. Does it really matter which one you used as long as fluoride is included in the ingredient list? Does it have to be approved by the American Dental Association? Or is your toothpaste suspect if that endorsement is missing? We'll ask our expert.
And then, what about flossing? What sort of dental floss should you use? What age do you start? How often? When? Time of day, when's the best to floss in the morning, in the evening, both time, after meals, when should we floss?
And here's my question -- if flossing comes along with brushing, do you floss before or after you brush your teeth? I have a dentist tell me two different things. So we'll let Dr. Janice Townsend be the tiebreaker and see what the recommendation there is, if it even matters.
So many details to consider. We'll also discuss routine dental visits, professional cleanings, X-rays, tooth decay, cavities, how to prevent them, spot them, treat them. And then, we'll cover fillings, root canals, crowns, implants, and whitening agents.
So lots of valuable practical information coming your way this week as we explore toothcare for kids and teens with Dr. Janice Townsend, who just happens to be the chief dentist at Nationwide Children's Hospital.
Before we get to her, I want to share some thoughts on a very spontaneous road trip that my wife and I took together last week. I was on vacation. So that's why there wasn't a podcast last week. But it was going to be a staycation, just got some things done around the house.
I think I've mentioned on this program. Or at least if you follow on social media, you've seen that we have seen Hamilton. In fact, we had a road trip to Chicago couple of months ago now and saw Hamilton there. So that kind of got us on a Revolutionary War kick. We then watched John Adams on Amazon Prime. Sense of Liberty was a History Channel three-episode event. And then, most recently, we've been watching Turn: Washington's Spies.
So we had this vacation week with really nothing planned. And we thought, you know what, let's just go on a road trip. We won't have the expense of flights, but where can we go in a day? And we've never been to Philadelphia. My wife was there once as a child and she couldn't really remember it.
And so, we took a road trip to Philadelphia. Stayed in the Thomas Bond House which was built in 1769. He's a physician, by the way. So then that became kind of a cool history thing to read upon him. He and Benjamin Franklin, together, started the Philadelphia Hospital. So that was kind of cool.
It was a fantastic trip. So we took in Independence Hall, the Museum of the American Revolution, ate at City Tavern. Not the exact same building that the founding fathers and the Continental Congress ate at in Philadelphia because that one burnt to the ground in the 1800s. But they rebuilt it to the same specs.
And so, we ate at City Tavern. We also went to Valley Forge, and of course, had a Philly cheesesteak at Jim's South Street Steak. That was fantastic. We went there just two or three days, and we didn't want a Philly cheesesteak every single day. Although, I know people in Philly now are cringing like, "What? You didn't try all three of the best kinds?"
But it was fabulous. It's really good. It was relatively inexpensive trip. Lots of fun. I would say that if you are a history buff or you're looking for a great educational trip with the kids, it's a good one. We really did enjoy.
I've read some bad reviews about Independence Park as a national park. I don't know, it was around the Fourth of July, I think. There was an editorial that I came across on social media but basically said everything's falling apart. That was not our experience at all. I thought it was a really terrific educational trip, lots of history.
So if you've never been to Philly, I suggest you check it out, especially if you're interested in the Colonial Period and the birth of the United States of America. Great trip with the kids, I think, too.
All right, a couple of housekeeping items. Don't forget, we are on social media -- Facebook, Twitter, LinkedIn, and Instagram. Love connecting with you there. We try to provide pediatric-focused and parenting-focused information for you in a daily basis, stuff that not's necessarily on the podcast but that we think would be helpful for you and your family.
Don't forget, you can also get in touch with me very easily. Just head over to pediacast.org. Click on the Contact link, I'd love to hear from you. So if you have an idea for a topic for the show, something you want to hear about, you have a question, want to point me in the direction of an article or a news story, please do so there. Again, that's at pediacast.org, the contact link.
Also, I want to remind you, the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. 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.
So let's take a quick break. We'll get Dr. Janice Townsend settled into the studio and then we will be back to talk about toothcare for kids and teens. That's coming up right after this.
Dr. Mike Patrick: Dr. Janice Townsend is chief of Dentistry at Nationwide Children's Hospital and an associate professor of pediatric dentistry at the Ohio State University College of Dentistry.
This is the third part of our super-duper 2019 dental series. We covered infant teething and toddler toothcare in Episode 423. We talked about dental injuries and emergency toothcare in Episode 429. Today, we're chatting about dental care and procedures for older kids and teenagers, including daily toothcare, cavity prevention, and treatment.
We'll talk about the importance of seeing a dentist on a regular basis. Why do those teeth need to be cleaned by the dental hygienist in the office? Why is simple brushing and flossing at home not enough? We'll have answers. We'll also explore root canals, dental crowns, implants, as well as tooth whitening agents.
So lots to cover this week as we're joined by pediatric dentist extraordinaire, Dr. Janice Townsend. Thanks so much for visiting us again today.
Dr. Janice Townsend: Thank you for having me.
Dr. Mike Patrick: Really appreciate you stopping by.
So what is the best way for kids and teens to care for their teeth on a daily basis? What should that look like in terms of routine?
Dr. Janice Townsend: Well, we don't have to make it too complicated. The main two things are brushing twice a day with a fluoridated toothpaste and watching what we eat, making sure we're not getting a lot of sugar, a lot of carbohydrates, things like that. Those are the two main things for keeping away cavities.
However, we want to keep our gums nice and healthy. We want to keep our breath smelling really nice. Flossing is a good addition.
Dr. Mike Patrick: Great. And when you say brushing a couple of times a day, does it matter when? So is this like first thing in the morning and before you go to bed? Should you brush after meals? What does timing look like?
Dr. Janice Townsend: Well, the two times a day is a minimum. But after breakfast in the morning and then last thing before bedtime. So, if we're going to have snacks, things like that, we need to wait. So that's out of the way and brush right before bedtime.
Kids that have appliances. It's a common age for braces. They may want to brush more often such as after meals just to get all the food out of the brackets.
Dr. Mike Patrick: Yeah, that makes sense. And then, does it matter what kind of toothbrush that we're using. There's so many different, there's sizes and soft bristles and hard bristles and then the motorized ones. Are there specific recommendations for the best toothbrush?
Dr. Janice Townsend: Brush with the toothbrush that you like brushing with. So if it's one of those things, I know some of the most expensive electronic toothbrush is out there. I actually don't like the way they feel. I do like one electric toothbrush that I use sometimes. But I use a regular toothbrush. It's one that you get from the drugstore most of the time. So it's whatever you feel like you can do well to clean your teeth.
Now, one thing with teenagers and maybe with our young teenager, something with a timer may be helpful. We want them to brush for at least two minutes. So if having that timer helps you remember to keep brushing, then that might be a reason to get an electric toothbrush.
Dr. Mike Patrick: And by electric, you're talking more the really vibrating kind versus like the one that's just twirls? You know the... Or both.
Dr. Janice Townsend: Both of them are technically electric toothbrushes. And there's, again, different kinds. I like the one that vibrates. The one that twirls, I always think it makes my gums hurt. But that's just me. Other people who feel the opposite.
Dr. Mike Patrick: Yeah, perfect. It's one of those things where for me personally the dental hygienist was like, "You got to get one of those sonic vibrating ones. Then, you have less plaque." Of course, I have the same dental hygienist, and then, she's like, "Have you been using it?" "Yeah, there's much less plaque." I don't if that's really true. She's still scraping in there, so I don't know.
But, anyway, it's really just use what you like. It's more important that you're using a toothpaste with fluoride in it and you're doing it a minimum of twice a day for two minutes each time.
And then, in terms of the fluoride toothpaste, the American Dental Association has their little seal of approval. What does that mean on the toothpaste?
Dr. Janice Townsend: The American Dental Association has a requirement for certain amount of fluoride. So we recommend 1,000 parts per million. So if you buy the one that has the seal, then you know that it's got the right amount of fluoride to help prevent cavities.
Most adult toothpaste do have the seal. Maybe if you're getting something that's really off of off brand and you don't want to use that anyway, some of the kids' toothpaste don't have the seal. And that's because they don't have the correct amount of fluoride to help prevent cavities.
Dr. Mike Patrick: But you still want the higher amount of fluoride even in kids.
Dr. Janice Townsend: Yes, you just want to make sure you use less.
Dr. Mike Patrick: Like a pea-sized amount. Okay, perfect, especially for the younger kids.
In terms of flossing, at what age would you recommend that you start introducing that?
Dr. Janice Townsend: Sometimes, I worry about introducing it too early and overwhelming families. It's hard enough sometimes to watch what the kids are eating, making sure they're not getting too much juice and they brush twice a day. So those are the basics I want to focus on.
Once a family has those basics -- they got it under control, they're doing that well -- that's the time to introduce flossing. And we have some very meticulous young children at age four that they can floss their teeth.
But, usually, as teeth start to get the permanent that transition into permanent teeth, flossing will help and it's primarily for the health of the gums. So that helps. And then, the added benefit of flossing regularly is to have good breath.
Dr. Mike Patrick: And just once a day on the flossing?
Dr. Janice Townsend: Once a day is fine.
Dr. Mike Patrick: So my wife and I have this, I won't say argument, but should you floss before you brush your teeth or after you brush your teeth? Or does it not matter?
Dr. Janice Townsend: That's probably something I should know, but I don't.
Dr. Mike Patrick: I actually asked my personal dentist, and I've had two different dentists tell me different. So then, my wife laughs when I'm wrong, and then I get to laugh when I'm right. But right or wrong, I don't really know.
The argument is that if you floss first than when you brush, anything that I guess came out you're brushing out of your mouth. But then, I had one dentist say, "Well, when you brush with fluoride then, when you floss, then you're getting the fluoride like moving it up between the teeth." And I guess I could see both sides.
Dr. Janice Townsend: I floss first because I like to brush after and just get out all the stuff that floss out just out of my mouth and that freshness. And it does make sense with the fluoride as well.
Dr. Mike Patrick: Yes, so you're on my wife's side on that one. And then, mouthwash, there's also fluoride rinse that we see. Are those recommended?
Dr. Janice Townsend: Well, actually, regular toothpaste has more fluoride than the over-the-counter fluoride rinses. So regular toothpaste has about 1,000 parts per million, something like an ACT Rinse has about 200 parts per million. So you're sort of rinsing away the fluoride with the fluoride rinse.
So it depends. If you're someone that can brush their teeth, spit out the toothpaste and be done with it, then you don't need to rinse. If you're someone that any bit of that grit or the leftover, you got to rinse them off over and over again, you're probably washing off most of the fluoride, and you might want to consider adding a rinse.
Dr. Mike Patrick: Okay, got you, that makes sense.
And then, how often should kids and teens visit the dentist? Every six months, is it just like with adults? Usually, we say twice a year, is that still the recommendation?
Dr. Janice Townsend: Absolutely. So we recommend a minimum of every six months. There are some kids that have special needs, maybe conditions where they build up tartar more frequently and they may need to come every three months.
But for most healthy children, every six months is fine. And these are the years that you don't want to skip. Because just like with everything else in the body, things are changing rapidly, teenagers, their diet is changing very rapidly. And we'll have kids that have been cavity-free their whole life, will take some radiographs, X-rays, just to make sure there's nothing. And all of a sudden, we will see the start of a cavity on every back tooth.
So we don't want parents to skip those visits in the teen years because those are times that we can see kids go from cavity free to needing many fillings.
Dr. Mike Patrick: When we're getting the teeth cleaned, so one reason to go over six months is to catch things early and deal with them and make adjustments if we need to in terms of our diet and how we're taking care of our teeth. But another reason is to clean the teeth and scrape that plaque off or tartar. Is that the same thing, tartar and plaque?
Dr. Janice Townsend: That's a great question. So it's actually the dental school word for it is calculus. And I use the word tartar because that's what's in the toothpaste commercials and families know it. But that is such a good point.
So whenever the children are young, four five six, they probably just have plaque. And plaque is a soft sort of biofilm. A good toothbrush will take care of the plaque. And sometimes, if you go to the dentist, they may just brush the kid's teeth with a toothbrush and that's okay. If anything, being really aggressive in there with that rubber cup and really abrasive polish might actually damage baby teeth.
But we do all go through a transition in our lives. It can be as early as seven. I've had some four-year-olds that are big calculus developers. Most kids I would say seven, eight, nine, that they start to get that calculus or tartar buildup.
And it's almost always behind of the lower front teeth and on the cheek side of the upper back teeth. And that can't be removed with a toothbrush. Even people who are very good brushers, some people are just really prone to tartar buildup. And they need to go at least every six months. And if they go then, the cleaning is usually a light cleaning. It's just a regular cleaning.
If you're one of those people that wait and don't go until every three or four years, you might actually have to get a deeper cleaning where you get the teeth numbed up and it has to go beneath the gums. So going every six months and getting that light cleaning is more comfortable, it's more affordable, and it's going to be healthier for the gums.
Dr. Mike Patrick: What exactly is... So you call that biofilm. What does that mean and how does it become hard like a calculus? When I hear calculus, I think bone, calcium.
Dr. Janice Townsend: That's what it is. So the biofilm, it's a mix of bacteria. It's a mix of sort of food debris. It's sort of the dried saliva. And again, a good scrubbing with the toothbrush will get most of it off. But for whatever reasons, some of that biofilm in those places that don't typically have good salivary flow can get harder.
Again, it's variable within patients. There are some patients that they build up a lot of tartar. We also have some kids that have different kinds of bacteria in their mouth, the chromogenic bacteria that their tartar buildup may be very dark. Maybe even a black tartar buildup.
It's not really any different but because the bacteria are different, it can look just not very aesthetic. And those are kids that might want to come to the office more often.
Dr. Mike Patrick: You talk about X-rays. Are those something that's done at least once a year? Or more often, less often, and are they safe getting all these dental X-rays?
Dr. Janice Townsend: Very safe, in the sense that if you're flying cross-country, if you're spending outside in a sunny day, the dental X-rays are much lower than a medical X-ray.
That being said, there's no safe lower limit for radiation, so we try to be very judicious. And so, a lot of this is based on carries risk. If this is a patient that is know to be a big snacker, they've had a history of cavities in their baby teeth, things like that, they sometimes might even get X-rays every six months. That's pretty rare for me every six months.
Kids that are moderate to high risk, usually about once a year. And then, once we get older into that sort of more permanent dentition and we've had some years of not getting cavities, we might even go to 18 months or to two years.
But that is something that whenever you go to the office, we really want the dentist and we teach our residents to just really be thoughtful about you, your past, your habits, and not overdo the X-rays. But at the same time, you're going to the dentist for a reason and that's to find out if you have a problem.
And if there's a cavity, especially in a permanent tooth that's big enough for you to see with your eyes, and that's the first time you find out about it, that's a pretty big cavity. So that's why those X-rays are needed.
Dr. Mike Patrick: That makes sense.
So with all of these that you're doing at these dental visits every six months, I'm sure that you deal with frightened and anxious children fairly often. How do you engage with them and get them to open their mouth and let you work inside?
Dr. Janice Townsend: Well, I think that's what set dentists apart from most of the surgeons, is we are doing surgery on awake kids and we expect a hug or a high-five after.
The really important thing is that the kids can do it. They can cope with dental treatment, most typically developing children, there might a little bit of anxiety. And that's normal and that's a healthy part of growing up and developing.
Usually, what we do is positive reinforcement, encourage them to keep doing the things they're doing great, like keeping their hands on their lap or opening up very wide. Sometimes, we want to let them know, you can do this. Well, you just listen, work with me.
We're almost like coaches. We use a lot of distractions. Sometimes, telling a story, letting them watch TV, things like that. So that's one of the big skills pediatric dentists learn.
Some of the saddest case are kids that are smart kids very typically developing but their parents have it in their head that they can't do it and that they need drugs. And then, when kids are told that and they hear that and they reinforce that, that's what they learn.
And there are times that children have a lot of cavities, are extremely young, age two or three, may need some pharmacological management to help get through that.
But again, most healthy school-aged children can get fillings done, crowns and extractions with just local anesthesia and maybe a mild sedative like some nitrous oxide. And a lot of times the parents will just give the kids the support, let them know, "No, you can do this," and really work with the dentist, most of the kids can get it done.
Dr. Mike Patrick: So for those parents who kind of insist right away on the pharmaceuticals, they must have had a traumatic experience themselves witnessing their child have a bad experience and that kind of plays in to the mental aspect of them not wanting to see their child go through that again.
But it really just takes the time and effort to engage with the child. And sometimes that happens and sometimes not depending on the experience, right?
Dr. Janice Townsend: And it's one of those things it is. It's part of life. And once a patient is an adult or older, it's not feasible to get to put to sleep to get your teeth cleaned in order to get a simple filling. And if kids don't learn that as they grow older and develop, it can be a big barrier. They just stop going to the dentist and then they can have some really severe dental problems, maybe even lose teeth.
But if they would have gotten that coaching at an early age, they could be cooperative, happy dental patient.
Dr. Mike Patrick: And then, there's the risk of the pharmacologic agents. We always are considering risk versus benefit. And certainly when you're sedating a child and you're working in their airway, and there's a chance for bleeding and aspiration and all those things and not breathing, it can become a medical emergency.
And so, if you are going to be using those kind of medicines, you want to make sure that you know how to resuscitate children, right? I mean, you read in the news, now and then, bad stories with that.
Dr. Janice Townsend: Sure. And it is one of those things that, again, this is a service we provide here at the hospital. It's a reason that a lot of kids are referred to us but we try to be very judicious and very cautious and very safe about it. So the sort of spectrum of kids that we're giving oral sedation to without an anesthesiologist present is pretty limited.
So again, sedation does and to an extent, it does add an element of risk. It also adds a lot of cost of families. It can be a big burden. And then, it limits who you can see because not all dentists provide that.
Dr. Mike Patrick: Is nitrous oxide still kind of a go-to in dentistry and for you guys, too, laughing gas?
Dr. Janice Townsend: Yes, nitrous oxide is something we feel very comfortable with. Some great benefits of nitrous oxide is it's one of the few agents that when you breath it, it really still doesn't have an impact on your body. And then, usually about one minute after you've stopped breathing, it's completely out of your system.
Dr. Mike Patrick: Now, we've talked a lot about some different words with carries and cavities. I think we've used that word, too, dental decay. Was there a difference between these processes, kind of like the tartar and plaque thing? Do these words mean different things?
Dr. Janice Townsend: They're sort of all parts of the same process. So carries is actually the disease. So even if the teeth don't necessarily have any holes in them, you might have the disease process, carries. Which is a cavity is the term we use for an actual hole or a defect in the tooth because of carries.
So it's sort of like carries is the disease process, chicken pox. Cavity is the actual spot you can see.
And then, decay is more of a generic term. It's a little older and again, it's a term that most people understand, but yeah, we do use carries, cavities, decay interchangeably. Yeah, we probably do confuse people.
Dr. Mike Patrick: And this is the breakdown of the enamel, which is the outer covering. How does that happen? How does tooth decay, dental carries, cavities, how do these occur?
Dr. Janice Townsend: Well, it's a bacterial infection. So we get the bacteria from our parents, thank you, mom and dad. And it is usually mom. And most people do have the bacteria that cause cavities.
So it's sort of ubiquitous. But it's one of those things that if we just have the bacteria, but we're not giving it a lot of space to grow by keeping our teeth very clean. And we're not feeding it a lot because what bacteria like are simple carbohydrates, mainly sugar. Then, that sort of infection stays under control.
But if we stop brushing and we let the bacteria grow on all the teeth, and if we're feeding it a lot of sugar, the infection gets out of control. And the bacteria actually sits in that, I'll use my terms... The bacteria sits in that plaque and it will consume the sugar, and then it produces acid.
It's a lactic acid. And that acid is what will demineralize the tooth. So that's when a tooth will look white but it will have a band that's really white usually around the gum. That's sort of a pre-cavity where the mineral has been leached out of the inside of the tooth but the surface is still intact.
Then, if it gets worse, then it will turn into a hole where more and more mineral has taken out and it's almost like a sinkhole. It's just sort of sinks in.
Dr. Mike Patrick: And it's acid dissolving the mineral out of the tooth that then leaves the hole. And then, what hurts?
Dr. Janice Townsend: If it hurts, it's gotten pretty bad. So usually, that enamel is that hard outer layer that protects the teeth. And inside the enamel is the dentin, and that's sort of a softer layer.
But just because you're having dental pain, it doesn't necessarily mean the cavities made it to the nerve. There's actually outcroppings of that nerve that are in that middle dentin softer layer.
So that pain is letting you know, "Hey, the cavity has gotten beyond the hard outer protective shell." And it's into the vulnerable part of the tooth and if it gets to the nerve, that's when you can have an infection, even to the point that sometimes kids have a swollen face.
Dr. Mike Patrick: In terms of the signs that this process is happening, I mean, in early stages, there may not be any signs that parents could tell at all, which is again, why you need to go every six months. But food sensitivity, sensitivity to hot and cold, can that be a precursor of actual pain?
Dr. Janice Townsend: Yes.
Dr. Mike Patrick: With this two.
So let's say, and we see this a lot in the emergency department, where kids do have sensitivity and teeth pain and maybe they have an appointment to see the dentist, but they still have several days. And the parents are like, "They can't take this pain anymore." What's the best way to treat the symptoms of that before they get in to see a dentist for definitive care.
Dr. Janice Townsend: Well, definitive care is the best. And the one thing we want to get away from is antibiotics. Antibiotics really don't make any difference with dental pain. But a lot of times, families can't get into a dentist. They'll go to a doctor instead. Doctors don't have the tools to treat the teeth so they'll give them an antibiotic.
And we all know that too many antibiotics can make the kids allergic to them, and then they can also stop working on that type of bacteria. So antibiotics are only indicated if there is a facial swelling where you can obviously see one part of the face looks different than the others.
So the best thing would be to get into a dentist and get definitive care, you can't postpone it with ibuprofen and Tylenol but you need to be taking it regularly, not just when it hurts.
Another concern is we have some families that put a lot of Orajel and benzocaine on. And that can be a concern. Some people have a dangerous reaction to that. We talked about this with the teething. It's called hemoglobinemia. And in those kids, they can have a life-threatening reaction to benzocaine, which is the product in something like an Orajel.
So the FDA has actually warned that it should not be used in children two and older. And even in older kids, there had been some case reports about parents just putting a lot of it on to help with dental pain, which may or may not probably causing minimal relief from the dental pain, but could set them up for this problem.
Dr. Mike Patrick: The infection, when you see the facial swelling, that's really more medical emergency, and you really do need to get in to see someone, and may need the antibiotics. Because when he infection gets to the soft tissue, the check, that's a different situation than the bacteria being in the gum and the tooth, correct?
Dr. Janice Townsend: Exactly. Sometimes, we'll have kids that come, and on the gum there will be like a little pimple, but otherwise, they're feeling normal. No temperature. Their face looks normal. That's not a medical emergency. And honestly, that one doesn't need antibiotics. Treating the tooth is going to fix that infection.
But once the infection goes beyond the gums and into the cheek, the eye, places like that, the lip, that is a medical emergency. A lot of times, these kids actually have to be admitted to the hospital for management.
Dr. Mike Patrick: Yeah, with IV antibiotics. Because if you have a cheek infection that can go around the eye, which then can track back and into the brain. And so, that can happen quickly. So it's something that you definitely, if your child has dental pain and then develops a fever, and their cheek looks swollen, that's something you do need to go to the emergency room for.
Then, let's talk about treatment of cavities. There's filling, but then also you drill. So like you're making the cavity bigger. Tell us about that and why that's useful.
Dr. Janice Townsend: Well, the concept behind this has changed a lot. Sort of our most conservative therapy is a sealant. So sealants are preventive. They coat the outer part of the tooth. Usually, just on the biting surface, they wouldn't work on like the front of you front tooth. But they work in places that we have pits, fissures, grooves.
And this is a plastic material that will help block the food from getting there. So even if there's bacteria there, they don't have anything to eat and they'll die. So preventably placing sealants is the best thing that we can do.
The other thing is sometimes we'll have a very small cavity that, again, it's in the hard outer layer. And in that case, I wouldn't drill it out at all. I would put a good sealant over it to help seal it and keep food away. And we know that that cavity is sort of going to arrest and stay in the same state.
Now, when we have a cavity that goes that hard outer shell and into the softer dentin of the tooth, that's when we do go in there, usually and traditionally, drill out the cavity and we place a restoration over it. If it's a permanent tooth, usually a filling. More and more were doing composite tooth colored fillings, but still indications I think for an amalgam silver filling on permanent teeth.
On baby teeth, still, the teeth are so small, the nerve of the tooth is so big that they don't always retain those fillings if it's a large cavity. We still do a lot of this stainless steel silver crowns because they last the longest.
Dr. Mike Patrick: So when you're drilling out the cavity, is that just to make it a more even surface that you're applying the composite to? Why do you do that?
Dr. Janice Townsend: The cavity is just sort of a load of bacteria. It's not healthy tooth anymore. Usually, you'll see us with an explorer feeling it. It feels mushy. So it's almost like whenever you lance or drain an abscess, we're removing that bacteria. We're getting rid of that bile burden and we're leaving behind healthy teeth, tooth structure, that our restorations will bond to.
Dr. Mike Patrick: Very interesting.
Dr. Janice Townsend: Now, there is a movement where there is more and more people who are putting filling without taking out all of the cavity, or maybe even putting a cap over a tooth without taking out any of the cavity. This is a new technique, contemporary.
Again, though, the dentists are trained to know when is that indicated, when could that be potentially be dangerous and how much is the right amount to take out versus leave behind.
Dr. Mike Patrick: One thought I had when you're talking about sealants, we're trying to keep the acid away from the tooth. But then, does that also keep fluoride away from the teeth?
Dr. Janice Townsend: The areas that benefit the most from fluoride are the smooth surface areas. So the smooth surfaces like the front of your tooth or the side of the back tooth in between the teeth, they get the most benefit from fluoride. So once fluoride was introduced, smooth surface decay was reduced tremendously.
Those pits and fissures of your teeth, though. They benefit some from fluoride, but they're big problem is, mechanically, food just get stuck down there and even we can look at some microscope pictures of these fissures. And some of these fissures are smaller than a toothbrush bristle.
So what the sealant does is that it's almost a mechanical barrier. So it keeps the fluoride away, but the fluoride can only do so much there.
Dr. Mike Patrick: And then, after we think about cavities being filled, sometimes we hear the word 'root canal'. What is a root canal and do kids get those?
Dr. Janice Townsend: Kids do get them. Root canal are one of those things that have... It's a very scary name, but it's really just like a deep filling that goes into the nerve of the tooth.
So you may need a root canal for a few reasons. One of them is if a cavity has gone through the hard outer layer, the softer middle layer and hit the nerve of the tooth, that nerve will die. So we need to go in there and do a root canal where we remove the nerve and then we put in a filling just so nothing else gets in that space. So that's all it is. It's a deep filling.
The other reason you may need a root canal -- and this is more common in our teenagers and children -- is trauma. If you fall and hit your teeth so hard, you can actually tear the blood vessels that bring oxygen circulation, nutrients to the teeth. And it's almost like if you string around your fingers and it turns purple after awhile -- don't do that -- it's the same thing.
That pulp's going to die because it doesn't have a blood circulation. So we, same thing, go in there. We remove it and then, we place a filling in the nerve.
Dr. Mike Patrick: I've had to have one root canal and it's for something call internal resorption. Apparently, which is autoimmune but maybe stems from an injury like a long time ago. Does that sound... I'm getting my second opinion here.
Dr. Janice Townsend: That's exactly it. And it's usually, again, the kids here listening today, your parents, it's usually from trauma -- getting a baseball to the face, falling off your bike, things like that. As you get to be my age, adults, it can happen to back teeth from maybe an overaggressive cleanings, things like that.
Dr. Mike Patrick: And then, a crown, we used that word a few times. This is just material on top of the tooth or is it a replacement tooth? Or could be either of those things?
Dr. Janice Townsend: It could be either. So fillings in permanent teeth, we can do a lot with filling material more so than in primary teeth. But there comes a point that there's just so much tooth missing that there's nothing to fill. It's missing.
So what we do is we go in and we make the tooth overall a little bit smaller and then we make a crown or a cap that fits all the way over the tooth to help seal it up. So usually, we'll do these if there's just a really large cavity, especially if it needed a root canal.
Dr. Mike Patrick: And in adult teeth, you may even take the tooth all the way down to the base. And then, the crown is like a whole new tooth that's glued on.
Dr. Janice Townsend: Sort of. One thing we do is especially in front teeth. We try to delay crowns as long as possible. Because as you're growing, your crown may look beautiful in a ten-year-old, but as they grow, you're going to start seeing that edge. The teeth always comes down, looks a little longer.
So usually, in these front teeth, we try to get by with just fillings if they fall and break it. And then, they can get a crown when they're older and they've stopped growth. And about older, I mean usually around 20 in females. Maybe even older than that in males.
Dr. Mike Patrick: So the whole tooth replacement with a crown is more of an adult thing.
Dr. Janice Townsend: That's more of an adult... And that's usually in conjunction with an implant. So an implant is when a tooth needs to be removed all the way. You'll place an implant, which is a metal anchor in the bone and then the cap goes over that. And that's one of those things that...
Dr. Mike Patrick: It's a big long process, right?
Dr. Janice Townsend: It's a big long process and it's also best to do after growth is complete. It's really sad sometimes because we'll have families that for whatever reason may be don't see treatment for a tooth, and they think , "Oh, I can just get it pulled and get an implant." And, especially, if it's a front tooth, that's not an option until a patient is in their 20s.
Dr. Mike Patrick: And then, let's talk prevention here a little bit. We've talked fluoride a lot. What magic does fluoride in preventing cavities? How does that work?
Dr. Janice Townsend: Well, fluoride has a lot of properties. We found that the naturally high areas of fluoride in parts of the country are patients that didn't get any cavity. So that's how we found out.
But what fluoride does sort of on a microlevel is when calcium is removed from the tooth, when we talk about the acid, the acid will take away the mineralization, leach out the calcium, the fluoride can go in there and replace it. And it will replace it in a way that makes it stronger than it was originally.
So it's one of those things, we all eat foods that aren't great for us, or maybe aren't the best brusher one day, so we've got some calcium coming out of our teeth. The fluoride goes back in and repairs it and it's in a nice balance.
The problem is when we go through long spells, we're not cleaning our teeth at all. We're eating way too much sugar that if we have so much acid attack on the teeth, even the fluoride can't come back to us. So that's why we have the mix of the fluoride and the healthy diet and the good oral hygiene.
Dr. Mike Patrick: When you say stronger, does that mean it's more resistant to dissolving with the acid?
Dr. Janice Townsend: Yes.
Dr. Mike Patrick: Okay, it kind of strengthens the whole structure so that the acid doesn't dissolve the tooth because some of the fluoride is there.
Dr. Janice Townsend: Yes.
Dr. Mike Patrick: Fluoride's kind of controversial that we read things on the internet. And often, if the community don't have fluoride in the water and they're trying to get it in the water, then there's some scare tactics about the problems with fluoride, and skeletal problems, and cancers. Can you speak to fluoride safety?
Dr. Janice Townsend: The fluoride isn't really controversial with anyone who's not trying to make money off of you. I mean, in the dental community, can you find some outliers out there, some dentists who say fluoride is bad? Yes, but they're usually, there's something else behind it. They probably also want to remove all of your fillings in, put in some safe, herbal-only fillings, things like that.
But within the dental community, there's no controversy. Fluoride is safe. We have about 100 years of evidence in America. What happens sometimes is these websites, usually a lot of websites, and if you look for them, they usually have advertisements for very expensive equipment that will take fluoride out of your drinking water at home that just happen to be on the websites.
But anyway, they'll find cases from maybe somewhere like India, where in American we would like to have an ideal of one part per million of fluoride in the water. And this might be a case where in a naturally fluoridated area that has way too much fluoride, maybe they have 15 or 20 parts per million.
And yes, a toxic amount of fluoride can be dangerous for bone health, things like that. Again, that's not the type of fluoride we're talking about as dentists for the drinking water or in your toothpaste.
Dr. Mike Patrick: These are very large doses over a long period of time. And just like anything, too much of anything, too much water can kill you. So you have to look at the whole picture and think risks and benefits. The amount of fluoride that's recommended to keep our teeth healthy is certainly safe.
Dr. Janice Townsend: Again, you will find things in journals but I think we both know that you can find a journal that will publish anything. And sometimes, you just have to pay the right amount of money to get it to publish. But in peer-reviewed reputable journals, these articles just aren't there.
Dr. Mike Patrick: Now, on the other hand, you can have some cosmetic issues with too much fluoride -- there's a reason that the recommended amount in community water supplies is the one part per million -- that we would call fluorosis. Speak to that.
Dr. Janice Townsend: So that's all developmental. So that's just while the teeth are developing. And that's why we have to be very cautious of our infants and of our toddlers. They want to be in charge of the toothpaste, but they shouldn't be. Mom and dad should. But once the teeth had stopped forming, then that's no longer an issue.
Dr. Mike Patrick: And so that would be a reason not to overdo the fluoride when they're really little. And we talked more about fluoride and fluoride in the water. And what if you live in the area that does not have fluoride in the water or you have well water, which could potentially have a large amount of fluoride in it.
We talked a lot more about that in Episode 423 where we discussed infant teething and toddler toothcare. And for those interested in listening to that, I'll put a link in the show notes, so folks can find it easily.
One last thing that I wanted to ask you about is your feeling on tooth whitening agent. People want really white teeth and there's all sorts of ways to get that. We even see at shopping centers, folks set up with their tooth whitening station. What do you think of that, particularly in relationship to children?
Dr. Janice Townsend: What's tooth whitening is something that when you're using appropriate products and under the supervision of a dentist, it's fun, and it's safe, and it's healthy. And it's one of those things that they were using bleaching. And it is, it's bleach, they were using it to help see if they could kill bacteria in gums and gum disease and they just happen to notice that not only did it work with gum disease, but also these patients' teeth were really white.
So whitening is safe. One of the things you want to look out though is...
Dr. Mike Patrick: But don't do it at the mall, right? See the dentist, correct?
Dr. Janice Townsend: I would see the dentist.
Dr. Mike Patrick: Okay, all right. We can say that.
Dr. Janice Townsend: We want to make sure the tooth isn't changing colors for a disease-related reasons. So we don't just want to do it all of ourselves. We also want to look at what are our habits? Are we drinking a lot of coffee? Are we drinking a lot of coke or soda that's got a color. And stopping those habits will probably will probably be more effective than just whitening away.
If you do use it, we want to use a very low dose to start with and work our way up to the stronger doses. And you can get some sensitivity, not only your gums but your teeth, but it is generally a safe thing to do.
Now, one thing we'll have is I think you probably heard the term milk teeth. Baby teeth are whiter than permanent teeth. They've always been that way. And so, sometimes parents will come just because those two teeth have erupted, and their yellower than the other bright white teeth and they get worried about that. That's normal.
And you shouldn't bleach teeth that early. You sort of want to wait till all the teeth erupt, all the permanent teeth. And then, if you're not thrilled with the color, talk to the dentist about it. They may do something in the office or they may recommend something that you can buy over the counter at the drug store.
Dr. Mike Patrick: But do it under the direction of your dentist. That sensitivity that you get, is that just the bleach entering into the tooth and irritating the nerve? It's not really causing a cavity, correct?
Dr. Janice Townsend: It's not causing a cavity but the teeth are pretty porous and that bleach can go through that hard enamel layer into the dentin layer which does have some nerve endings. Some of it can also be from the gums. Whenever I bleach my teeth, usually, my gums are sore but my teeth themselves don't have any sensitivity.
Dr. Mike Patrick: And it's usually a temporary issue.
And that's okay, for you, if there are teenagers that wanted to do that, that would be find. But younger kids, probably not so much.
Dr. Janice Townsend: No. And they're probably not that concerned with their teeth. Again, I think you can check in with their dentist.
Dr. Mike Patrick: We really appreciate you stopping by. If you don't mind, remind us again about the dental program here at Nationwide Children's Hospital. The training program that you have and then the services you provide.
Dr. Janice Townsend: Yeah, well, we have, this is one of the largest dental departments of any hospital in the country. We're very proud. We have a very hardworking team -- general dentist, pediatric dentist, our dental residents, hygienists, and our assistants.
We do have clinic at our Livingstone Ambulatory Center. It's a beautiful new, 30-chair clinic. If you haven't been over, you should come check it out.
We see patients for regular cleanings and we see the whole range of patients. We see kids that are perfectly healthy. They just want to go to the dentist at a hospital setting.
Other patients really like to come to us because their doctors are at the hospital as well, and they want to be in that same system. So most of what we do is routine -- cleanings, fillings, things like that.
We do get referrals of some younger children or children that just can't cooperate and have a lot of cavities, unfortunately. And we do provide sedation and hospital dentistry services for them.
Dr. Mike Patrick: And imagine you also take care of a lot of the complex medical patients, kids who breathe through tracheostomy and folks who have all sorts of chronic illnesses that would not necessarily be able to cooperate very easily.
Dr. Janice Townsend: Absolutely. We really want to support the different patients that are treated here at Nationwide Children's. So we see a lot of referrals from our oncology department, our hematology department, some of the kids that have hemophilia. And yeah, it's just in hospital environment where we can talk to their doctors. I think a lot of families just feel a little more secure.
Dr. Mike Patrick: We'll put a link to Pediatric Dentistry at Nationwide Children's Hospital. You also have walk-in hours, right?
Dr. Janice Townsend: We do. We try to reserve this for just emergencies, not convenience. But yeah, we don't want kids to suffer in pain or wait. Or we want to be that place that you can go whenever your kid's on the playground and gets hit with a baseball or falls off their bike. So yes, we do have walk-in hours every weekday for emergencies, such as trauma or such as pain that just can't be controlled with over the counter.
Dr. Mike Patrick: And those are sort of 9AM and 1PM, but it's first come, first serve, I think.
Dr. Janice Townsend: It's first come first serve.
Dr. Mike Patrick: So if you get there late, they may not have room to get you in.
Dr. Janice Townsend: Yeah. It's just better for the kids and better for everyone to have plans, scheduled appointments, and to get ahead of emergencies. But we're definitely here for families that don't have anywhere else to go.
Dr. Mike Patrick: Great. So we'll links in the show notes to pediatric dentistry here at Nationwide Children's. Also, those previous episodes that we had done together, Infant Teething and Toddler Tooth Care, Episode 423, and Dental Trauma and Emergency Tooth Care, Episode 429.
And then, all three of these episodes will be on a playlist on SoundCloud. So folks can, if you want to listen to all three of them, they'll be right there for you.
We'll also have a link to the American Academy of Pediatric Dentistry. And they have a really wonderful frequently asked question guide, it's a reference guide with quick answers to lots of common questions. We'll put a link to that in the show notes as well.
So Dr. Janice Townsend, chief of Pediatric Dentistry here at Nationwide Children's Hospital, thanks so much for stopping by today.
Dr. Janice Townsend: Thank you.
Dr. Mike Patrick: We are back with just enough time to say thanks once again to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that.
Also, thanks to our guests this week, Dr. Janice Townsend, chief of Pediatric Dentistry here at Nationwide Children's Hospital.
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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.