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Pediatric Dental Care

Sarat Thikkurissy DDS, MS and Nick DeBlasio, MD

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To discuss the preventative dental care of the infant and child including the use of fluoride.


  • Brushing should be started with the eruption of primary teeth and flossing should be started when there is no visible gap between any two teeth.

  • Children can often start to brush on their own when they can tie their shoes or write in cursive. Their work should be checked by their parents.

  • Good ways to avoid carries include transitioning to a regular cup as soon as possible, avoiding juice especially between meals, and brushing before bedtime even if a feed is part of the bedtime routine.


  • How should we approach a baby who is born with teeth? Teeth that are present at birth are called natal teeth and those that appear within the first 30 days are called neonatal teeth.

    • The concerns that should be addressed are 1) trauma to the tongue which can lead to pain and feeding problems and 2) aspiration risk as the tooth and root can be incompletely formed.

    • These teeth will typically be pulled by a pediatric dentist but families should be warned that there are often the primary dentition and the child will be missing a tooth until the secondary dentition comes in.

  • The first teeth typically erupt at 6-7 months, what dental care should parents do prior to that? Prior to the eruption of the primary dentition the goal is to establish good habits for oral hygiene and wiping down the gum pads to prevent accumulation of plaque.

  • How do you approach teething pain? Cryotherapy, with chilled teething rings or even spoons, pacifiers, nipples cooled in ice water can be beneficial. Topical anesthetics like topical benzocaine are typically not recommended. They may be recommended for older kids starting at 18 months, 24 months, or if teething is causing problems at mealtime. If there are significant feeding problems other etiologies should be considered like otitis media or sinusitis.

  • When should brushing be started? As soon as teeth are present brushing should be started, toothpaste can be used depending on other sources of fluoride and the risk factors present. If toothpaste is used the amount should be the size of a grain of rice.


* Editor’s note: a 2014 AAP policy statement suggests  universal use of fluoridated toothpaste the size of a smear or  grain of rice from tooth eruption and increasing to the size of a pea after the third birthday.


Section On Oral Health. Maintaining and improving the oral health of young
children. Pediatrics. 2014 Dec;134(6):1224-9. PMID: 25422016

  • What kind of toothbrush do you recommend can we use the toothbrush that fits over the parents finger? The type of brush is not that important. It is more important that the parent is inspecting the teeth to make sure brushing was effective. The type of toothpaste does matter and whitening toothpaste should not be used as the teeth are thin and the enamel can be easily abraded.

  • How do we deal with children who will not cooperate with brushing? Establishing a family routine is important. Adults brushing their own teeth at the same time can help.

    • If needed, the knee to knee position can be used. The two caregivers sit facing each other with their knees touching. The child sits on one caregiver and lays down with the child's head on one person's lap. The person with the toothbrush is responsible for the head and the other person is responsible for securing the child’s legs and arms.

  • When should flossing be started. This should start when there is contact between the teeth and the area is “closed”. Closed means we cannot see in between the teeth and brushing will no longer be effective in this area.

  • When should the first dental visit occur? The first visit should be within six months of eruption of the primary dentition. For most children this means children should be seen by 12 months. The AAP recommends that all children establish a dental home by one year of age.

  • What should we do with children who are not able to find dental care in the first few years of life. Where dentists are not available for young children, pediatricians can apply and bill for fluoride varnish. If pediatricians are doing this they should make sure be addressing the general oral health that would be addressed at a dental visit. This may include, dietary guidance, evaluating how much fluoride is being used, anticipatory guidance for dental trauma. The United States Preventive Services Task Force recommends the application of fluoride varnish by primary care providers starting at primary tooth eruption.


Moyer VA; US Preventive Services Task Force. Prevention of dental caries in
children from birth through age 5 years: US Preventive Services Task Force
recommendation statement. Pediatrics. 2014 Jun;133(6):1102-11. PMID: 24799546


  • How do you address bedtime brushing and the last feeding of the day? Families can be resistant to “waking” a child after the last feed to brush. The best answer is that they should brush before bedtime. If we cannot get people to brush after the last feed then try to avoid anything other than breast milk after brushing and to at least try to wipe down with a washcloth. Breast milk is non-cariogenic.

  • What other advice can we give to prevent caries? If at all possible it is best if families can skip the sippy cup and go right to a regular cup. Juice should be avoided and if it is going to be given it is better to give with meals not between meals. Faquershe does not recommend dilution of juice.

  • At what age should we be concerned if a child does not have teeth? Generally sequence is more important than timing.

    • Looking at the larger picture with the growth curve, looking or systemic symptoms can be important. Dental radiographs can be done to evaluate if teeth are present and developing normally but there is unlikely to be a dental intervention even if there are no teeth at two years.

  • What are the dental concerns with premature infants? Premature infants may have later eruption of dentition and may have many teeth come in a short period of time.

    • Enamel hypoplasia can be seen with prematurity in addition to systemic illness or medication use.

    • Endotracheal tubes that rest along the alveolar ridge can displace the teeth and even cause clefting of the alveolar ridge.

  • When can children brush on their own? Six to eight year olds often will express more interest in independence. Children have the dexterity to brush their own teeth when they can tie their shoes or write in cursive. As children start to brush on their own parents should be checking their work. There are even over-the-counter mouthwashes that can show which areas have been missed.

  • What type of toothbrush should children be using? A soft toothbrush is the recommendation. There is no good reason to support using an electric over a manual toothbrush and whatever the child will use should be encouraged.

  • Should children use mouthwash and if so at what age? Typically children can spit out mouthwash around six years of age. Children should not use alcohol based mouthwash.

  • How do you address the statement that caring for the primary teeth is not important as they are going to fall out anyway? There are other concerns including difficulty with articulation, difficulty with eating, social concerns and even self esteem.

    • There is more literature on the oral-systemic connection that oral health affects overall health.

  • As pediatricians we look for sinusitis, reflux or allergies when we have the chief complaint of bad breath. How do you approach this as a dentist? This can be approached from front to back. First evaluate the teeth for plaque, evaluate the tongue to see if it is catching food debris, and then look at the tonsils. Dentists will also consider reflux, food allergies or food intolerance.

Should we worry about thumb sucking? If thumb sucking stops by the four years old range any skeletal change will self correct with age. Thumb sucking beyond 4 years may lead to need for orthodontia. Management should not be too aggressive in younger children especially if there are other current stressors or toilet training.

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Near Hits and Direct Misses Full episode audio for MD edition 195:00 min - 91 MB - M4AHippo Peds RAP July 2016 Summary 582 KB - PDF