Once a tooth is numb, the child should not experience any further discomfort. However, there are a lot of sights and sounds that can unnerve a child into thinking that what is happening is painful. Since a drill has to be used to clean out the decay and shape the inside of the tooth to hold a filling, the chatter of the drill’s bur, the water spray, and the high pitch sound can startle some children. At our office, we show the patient every step that we are about to take before we do it. For example, we take the high speed handpiece and hold their hand up to it and let them feel the water spray. We tell them that the water spray is going to clean out all the cavity bugs. With their fears allayed, most children will be still while the cavity is being drilled out. We tell them that the water spray will tickle their teeth, so the vibration of the drill is well tolerated. Taking the extra time to demonstrate what’s going to happen is well rewarded with a calm, cooperative child.
Filling cavities in baby teeth can be very important. Many people think that just because the baby teeth fall out eventually, you don’t need to be concerned about caring for them. Baby teeth are important to keep space open for the permanent teeth. If a baby tooth is lost too early, the teeth will crowd up making any subsequent orthodontics much more difficult. And if a cavity gets too deep, the tooth could abscess which can cause a lot of pain, not to mention the chance of serious infection. One of the worst parts of my job as a dentist is seeing a child writhing in pain with a toothache only to find out that this is their first trip to the dentist. It’s not too hard to imagine how much they will look forward their next trip to the dentist. It is also very hard to get profound numbness on an abscessed tooth which makes the experience that much worse. By pre-planning and catching things early, teeth can be filled painlessly on children.
When filling children’s teeth, I ALWAYS use local anesthetic on children. My practice includes a large segment of adult patients requiring sedation. The overwhelming reason for their extreme fear of the dentist is because their dentist didn’t use novocaine when they had their teeth filled as a kid. By numbing teeth ahead of time, a tooth can be drilled on without any pain whatsoever. Fear of the “shot” is a very common issue in children (not to mention many adults). We try to make that part of the visit as easy as possible for the patient. We start with a topical numbing gel that is placed on the gum at the injection site with a cotton swab. Once the gum is fully numb, the child is told that they will feel a little “pinch”. The anesthetic syringe is passed to the dentist out of sight of the patient. By quickly inserting the needle into the numbed gums and very slowly injecting the anesthetic solution, the child experiences little to no discomfort. It is such a heart-warming feeling to hear a child run out to the waiting room saying “Mommy, Mommy – I didn’t have to have a shot! He just pinched my gums.”
Getting a child comfortable and relaxed once seated in the dental chair is paramount in having a good experience with a filling appointment. We have TVs in the ceiling that can show cartoons or children’s programming which can get most kids at ease. For those who continue to have reservations, many times just taking the time to explain what is going to happen can be enough to allay their fears. If a child continues to be unruly, the next step is nitrous oxide (laughing gas). This “Happy Gas” can be the final calming factor for many children. Every once in a blue moon, we will come across a child who is so fearful that they cannot be safely controlled. We do not use papoose restraints in our office, so sedation is the only alternative in those cases. Sedation of children is best handled by pedodontists. They have special training in sedating children who have a very variable response to many of the medications that are used. About once in every five years, I refer a child to specialist care.
With patience and a gentle demeanor of the dentist, most children can have cavities filled with minimal fear and discomfort. As a patient in preparation for the visit, don’t use phrases like “Oh, it won’t hurt”, or “It will only hurt a little bit”. Use positive statements, like “Remember how you got your teeth cleaned? Well, Dr. G is going to clean out all of the cavities bugs”. The question of “Am I going to get a shot?” frequently comes up. The best answer to that is “Dr. G has a special pincher that will put your tooth to sleep so that you won’t feel it when he cleans out the cavity bugs”. When the day comes, we allow the parents to bring the child back into the treatment room, but when the time comes to start the treatment, we ask the family to go relax in the waiting room. We have found that 99% of pediatric patients are much more comfortable and much less fearful without a parent to get attention from. I have had screaming children clutching mom’s or dad’s arms, holding on for dear life, only to turn into placid little angels within 15 seconds of the parent’s departure.
Regular dental exams and cleanings are extremely important for children in order to maintain their dental health. In our office, a routine cleaning visit consists of a thorough oral and dental exam. This includes a screening for oral cancer, an assessment of the gums and oral mucosa, a check for any growth abnormalities, visually checking for cavities in the teeth, and an orthodontic evaluation. Bitewing x-rays are taken of the back teeth in order to detect cavities in their early stages. Many times, if a cavity gets large enough to be seen visually, it could be already deep enough to be in the nerve which would greatly increase the cost to repair. The teeth are gently polished to remove plaque and then the teeth are bathed with a high concentration of pleasant-tasting fluoride. We have many flavors to choose from to satisfy event the pickiest of tastebuds. We recommend the routine check-up and cleaning to be every 6 months. Cavities tend to grow much quicker in children than adults, so an ounce of prevention is so much better than the pound of cure.
Your child’s first trip to the dentist is a very special time in their life. Just like the first haircut, it can be fraught with fright. In the days before, it is best prepare them with positive comments. Statements like – “It will be a lot of fun”, or “They will shine your teeth so you have a pretty smile” go a much longer way than -“Oh, it won’t hurt”. In our office, we go out of our way to make that first visit a special occasion. We don’t force anything on them, but we positively reinforce good behavior each time they try something new. We have TVs in the ceiling that can play cartoons. That goes a long way to soothing any uneasiness. Then, to cap off the visit, there is a trip to the treasure chest filled with toys. And hopefully, there will be a picture taken to display in the “No Cavities Club”. Having a good experience during the first trip to the dentist can be tantamount in having good behavior in future visits.
In my last blog, I discussed in-office bleaching. The other method for lightening teeth is done at home. There are over the counter products and ones that are professionally available at your dentist’s office. The over the counter products seem to work OK for teenagers and young adults, however, with older adults, the professional variety works much better. My speculation is that the stains have been there much longer and are more resistant to the bleaching process.
In our office, we make a custom tray, essentially an ultra-thin, clear mouthpiece to hold the bleach in the mouth. The bleach that we use is slightly viscous and sticky so it doesn’t run all over the mouth during use. I instruct my patients to sleep with the mouthpiece in all night. The process can take anywhere from 2-6 weeks, but the bleaching solution is not near as harsh as the in-office variety and is much kinder and gentler. This greatly reduces the incidence of sensitivity. Studies have shown that after six months, the results between in-office and at-home bleaching is exactly the same. And other studies have shown that patient satisfaction hovers around 96% positive for at home and less than 50% for in-office.
There are two main methods for bleaching teeth: in office or at-home. In an office setting, a rubber-like substance is painted on the gums and then light cured. An extremely strong solution of hydrogen peroxide, usually 35%, is applied to the front teeth surfaces. The solution is left on the teeth for long enough to leach into the enamel and oxidizing the stains. This usually takes about 15 minutes. Some dentists employ the use of lights to accelerate the process. The lights can cause overheating of the dental pulp which contains the nerve and can greatly increase the sensitivity to temperatures. Studies have shown that the use of lights or “lasers” makes no difference in the final results. If there is an increased lightening right after the appointment with the use of lights, it has been shown that that is due to dehydration of the tooth surface and the color will return once the teeth have rehydrated. There are some desensitizing that the dentist can apply afterwards. These contain potassium nitrate. There are also toothpastes that are specially made for sensitive teeth that can help make an in-office bleaching procedure much easier to tolerate.
When bleaching one’s teeth, it must be kept in mind that the bleaching process will not effect the color of dental restorations such as tooth-colored fillings, bonding, or porcelain laminate veneers or crowns. It will not harm porcelain, but scanning electron microscope studies have shown some some minor pitting in composite (tooth-colored) restorations. Hypocalcified and fluorosed areas have stark white splotches. When initially bleaching the teeth, these areas tend to stand out dramatically, however, as time goes on, the surrounding tooth structure will begin to lighten, thus allowing the hypocalcification to blend in better. Teeth bleaching will not remove these splotchy areas, just make them less noticeable. Many people have grey stains in their teeth. These stains can be very resistant to the bleaching process. The products that cause the grey color do not appear to oxidize as well. On the other hand, yellow stains are very amenable to bleaching and will lighten very well. The nice thing about the grey stain is that it is not as noticeable from a conversational distance as the yellow, so the teeth can still have a light, appealing appearance even with some residual grey.