Common Questions about Kids and Their Teeth

Is it necessary to fix a cavity in a baby tooth? It’s going to fall out anyways, right?

Many parents ask this question, and the answer depends on how much time is left before the tooth will fall out and be replaced by the developing adult tooth. Consider the following tooth loss chart:

As you can see, the front baby teeth are lost around the ages of 6-8 years, while some of the back teeth stay in the mouth until 11 or 12 years of age. So if there is a cavity on a baby tooth that is going to be in the mouth long enough to cause a problem, it is recommended to fix it.

What problems can arise from an untreated baby tooth with decay?

If a baby tooth has a cavity, the decay will continue to grow until it eventually hits the nerve of the tooth. The amount of time this takes varies on a case by case basis, but it can be as little as a few months or as much as a year or more. When the decay reaches the nerve, the bacteria from the cavity enters the nerve, causing a painful toothache, and eventually the death of the tooth. Once the baby tooth dies, the bacteria will build-up inside the tooth and cause an infection in the surrounding gums. This infection can be identified on an x-ray and oftentimes presents as an abscess or “bubble” on the gums (although not always). Once infected, there is no solution and the baby tooth will need to be taken out.

Advancing decay in a baby tooth. As decay progresses and reaches the nerve, pain, infection and abscess result, necessitating extraction.

So the baby tooth has to be extracted, why does that matter? It’s supposed to come out anyways, right?

If a baby tooth needs to come out before the underlying adult tooth is ready to occupy its place, eating and nutrition can be compromised as the child does not have a full set of teeth to chew properly. The neighboring teeth can also collapse into the empty site, affecting the proper development and eruption of the adult tooth. To prevent the movement of the neighboring teeth, a fixed metal appliance called a space maintainer is cemented to the tooth behind the open space. This space maintainer stays in place until the adult tooth erupts above the gums. While a space maintainer can effectively save the space for an unerupted adult tooth, it’s certainly not as effective for eating. Taking the proper steps to avoid needing the space maintainer in the first place is by far the superior situation and what we strive to achieve for all of our patients. Think of a space maintainer as a last resort when all other prevention and treatment measures have failed!

Space maintainers help prevent loss of space when a baby tooth has to be taken out prematurely

So I get it, it’s best to detect and fix decay before it turns into a bigger problem…so what is the best way to fix cavities on baby teeth?

The proper way to restore a decayed baby tooth depends on the extent of the decay. If it’s a small or even moderately-sized cavity, a filling will do the trick.

If the cavity is large or close to the nerve, things get a little more complicated. The reason is because the nerve of a baby tooth is very sensitive and will become irritated or inflamed if a filling is placed within its vicinity. If the decay is within 2 mm or less of the nerve, a pulpotomy is indicated, which involves the removal of the top part of the nerve. This procedure is also commonly referred to as a root canal for a baby tooth. A significant amount of tooth structure is eliminated during decay and nerve removal, meaning a stronger and more durable stainless steel crown needs to be placed over the entire tooth to restore it to its original form and function.

For a moderately or severely decayed baby tooth where the cavity is close to or touching the nerve, a pulpotomy and stainless steel crown is indicated. On the left, an x-ray shows decay almost touching the nerve. In the middle picture, two pulpotomies have been performed, and the white squares in the middle of the teeth are medicinal cement that fill the nerve space after its removal

Extraction of the baby tooth is indicated for the following reasons:
● If the cavity has reached the nerve and pain is present; research shows that performing a pulpotomy on a symptomatic baby tooth has a very low chance of success, so tooth removal and space maintenance should therefore be considered the best treatment option;
● If there is an infection present, identified either on the x-ray, clinically (abscess on the gums), or reported symptoms (pain);
● If there is so much tooth structure destroyed by decay that not enough remains to retain a stainless steel crown;
● If the baby tooth had work done previously (filling or pulpotomy), and pain or infection develops;
● If the baby tooth is “over-retained” and is blocking the proper eruption of the adult tooth. An adult tooth is supposed to come in directly below the baby tooth and push it out during eruption, but if the adult tooth gets off course, it can come in behind, in front or to the side of the baby tooth, causing the two teeth to occupy the same space and forcing the adult tooth to erupt in the incorrect position.

My child had a pulpotomy and stainless steel crown done, but an infection still formed. Why is that?

A pulpotomy and stainless steel crown, while usually an effective way to restore and maintain a moderately or severely decayed baby tooth until it’s ready to fall out on its own, is only about 75-80% successful. The reason lies in the hundreds of tiny accessory canals that can still harbor bacterial accumulation and cause an infection around the roots of the tooth. Sealing these canals is impossible as they are too microscopic and too numerous for dental instruments to treat.

The black area beneath the spot where the two roots split is an infection, which results from bacterial accumulation in the tooth’s accessory canals

Pulpotomies are not meant to last a lifetime; they only need to last long enough for the tooth to exfoliate. Unfortunately, in some cases, the bacteria will accumulate quickly enough to cause an infection before the tooth falls out. In these cases, extraction and space maintenance when appropriate is indicated.

My child had a filling done, and later on an abscess formed around the tooth. Why is that?

Even with moderately deep fillings, the tooth can sometimes react adversely and result in nerve death. The subsequent accumulation of bacteria in the dead nerve canal space leads to infection and similar to a failing pulpotomy, extraction and possible space maintenance is indicated.

What’s the best way to prevent cavities on baby teeth?

Baby teeth have very thin enamel when compared with adult teeth, so cavities form relatively easily and progress quickly. This makes good oral hygiene and regular dental visits very important for children! You should be helping your child brush for 2 full minutes twice a day, once in the morning and once before bed. Use a toothpaste with fluoride; although it’s not good for the body if ingested in large quantities, it’s very beneficial for the teeth by helping to remineralize and strengthen the enamel. Per the American Academy of Pediatric Dentists, you should be brushing your child’s teeth with a fluoride-containing toothpaste in the amount of a grain of rice if he or she is under three, and the amount of a pea if he or she is three or over. This small amount ensures your child reaps the oral benefits of fluoride without risking the systemic damage of ingestion, even if it is swallowed. To help prevent cavities between the teeth, help your child floss once per day, and keep in mind he or she lacks the dexterity to do it by him/herself until the age of about ten.

How soon should I bring my child to see the dentist?

A child’s first visit should be at one year of age. Baby teeth start coming in at about 6 months, and should all be erupted by one year. You should bring your child back every six months for regular check-ups after his or her initial visit.

Will my child need braces?

Most children are ready to begin braces at around age 12. This is the average age at which all baby teeth have been lost and all adult teeth are in place (except for the wisdom teeth). There are some exceptions when earlier treatment is indicated, such as a crossbite or severe crowding, for which expansion of the jaw or palate could help alleviate some of the lack of space prior to regular braces at 12 years old. But for the most part, malpositioned or crooked teeth from the ages of 6 to 12 are left alone while development of the jaw and skull progresses naturally. This is called the ugly duckling stage with good reason, but not to worry, your dentist will let you know if and when your child is ready for braces!

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