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Repairing Children's Teeth
When dentists talk about restoring a tooth, they are referring to any procedure, such as a filling, that returns the tooth to its original shape and function. There are several reasons why it might be necessary to restore children's primary and permanent teeth:
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Decay (dentists call it caries)
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Trauma —
a broken or cracked tooth
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Developmental defects that cause teeth to be too small or improperly shaped
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Endodontic therapy (pulpotomy or root-canal therapy)
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Noticeable discoloration
Restoring Children's Primary Teeth
Some people may believe it's not necessary to place a filling in a primary tooth because the tooth eventually is going to fall out and be replaced by a permanent tooth. However, primary teeth are important, not just for cosmetic reasons, but for chewing food and allowing speech development to proceed normally. The primary teeth also help guide the permanent teeth into position.
In addition, tooth decay is an infection, so if a primary tooth is decaying, the child has an infection that ultimately could affect his or her general health.
A primary tooth can be restored with a filling or a crown, depending on how much of the tooth's structure is still healthy. Compared with permanent teeth, primary teeth are more likely to need a crown if they are decayed extensively because primary teeth are smaller and have thinner layers of enamel (the outer surface) and dentin (the layer beneath enamel). Large fillings in primary teeth tend not to last as long as crowns.
Placing a filling in a primary tooth will not make it less likely to fall out when it is time for the permanent tooth to come in.
Restoring Children's Permanent Teeth
Children's permanent teeth generally are filled in the same way as adults' permanent teeth. The making and fitting of a crown, however, is very different.
A child's crown (usually made of stainless steel) is completed in a single visit. In an adult, a crown is done in several visits, including on for taking an impression and placing a temporary cap, and another for fitting the crown (usually gold or a semiprecious alloy) and cementing it into place.
Filling Types
Fillings in children —
in both primary and permanent teeth —
can be metal (amalgam) or plastic (composite resins, glass ionomers, or a combination of resin and glass ionomer called a resin-modified glass ionomer).
Metal
Amalgam has been used as a filling material for more than 100 years, and still is used to fill children's teeth. The advantages of amalgam are that it:
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Has a long history of successful use, especially in the back teeth (molars), which are exposed to extreme biting and chewing forces
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Generally takes less time to place than plastic fillings
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Is less expensive than plastic fillings
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Is more reliable if the decay is between two back teeth or involves several tooth surfaces
However:
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Some people are concerned about the mercury in dental amalgam, although no study has shown that it causes any ill health effects.
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More tooth structure has to be removed to place an amalgam filling because amalgam is not bonded chemically to the tooth. Instead, it is held in the tooth by the way the tooth is shaped by the dentist.
Plastic
Plastic fillings have several advantages:
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They are tooth-colored, so they blend in with the rest of the tooth and other teeth.
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They are bonded to the tooth, which helps seal the filling and prevent decay around it.
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Glass ionomer and resin/glass ionomer fillings release fluoride, which helps strengthen the tooth and prevent more decay.
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Generally, the dentist can cut a smaller hole in the tooth when placing this type of filling than when placing an amalgam filling because it is held in place by the bonding and not by the way the tooth is shaped when the dentist removes decay.
However:
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Plastic fillings cost more than amalgam fillings.
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Placing a plastic filling is more complicated, which means your child may spend more time in the dentist's chair.
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Although the American Dental Association found no difference in the durability of plastic and amalgam fillings over three years, it is not known whether plastic fillings hold up over longer periods. Plastic fillings in the back teeth are less likely to wear down if they are small and not subject to heavy biting and chewing forces. These materials continue to improve.
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Some children are allergic to methyl methacrylate, an ingredient in plastic fillings, but this is rare.
Sedative Fillings
Sedative fillings are placed on a tooth to reduce pain from irritated or inflamed pulp —
the blood vessels and nerves in the center of a tooth. A sedative filling calms the pulp and reduces the chance that saliva or bacteria will leak into the tooth and irritate the pulp in the future.
Sedative fillings often are placed directly into the tooth without any drilling. One of the most common types of sedative filling is zinc oxide and eugenol. This contains oil of cloves. Glass ionomers or resin/glass ionomers also are used for this type of filling.
A sedative filling is considered an intermediate measure, and often is used in very young children who can't tolerate sitting in a dentist's chair long enough to receive a regular filling. A sedative filling also may be used for a child who has a traumatized tooth and needs immediate relief.
Sedative fillings can last for years. Your dentist should regularly examine the sedative filling to be certain it is still in place.
Concerns At Different Ages
An early negative experience can have lifelong effects, so your dentist should take your child's emotional and psychological well-being into account, as well as what is best for your child physically.
Managing your child's fears is extremely important, as it can shape your child's views about dental visits for the rest of his or her lifetime.
Managing anxiety will be different for each child, and older children may not necessarily be less nervous or afraid than younger ones. Your dentist should work with your child to ensure that the experience is as pleasant as possible.
Fillings can be placed in children with braces. If your dentist can't reach the decay, your orthodontist would need to remove a band or bracket to make the tooth accessible. Children undergoing orthodontic treatment should see a dentist three or four times a year instead of the usual twice a year because it's more difficult for them to keep their teeth clean.
Placing A Filling
Young children may have some difficulty undergoing dental treatment, but the experience can be a positive one if the dentist has training and experience with this age group. Here's how a filling is placed.
Local anesthesia
Your child will receive a topical anesthetic —
a gel or ointment —
on a small area of the gum or inner cheek. Once the area is numb, the dentist will inject a local anesthetic, which will numb the teeth and surrounding area for three or four hours.
Managing Anxiety
Pediatric dentists focus on the care of the child, not just the child's teeth. Pediatric dentists can help ease a child's anxiety and cope with the difficult situation that a dental visit can be.
Some coping techniques include:
-
"
Tell, show, do "
—
the dentist tells a child what is about to happen, shows the child the instruments involved and what is going to happen, and then does it.
-
The dentist uses a soothing voice to calm a child.
-
Whenever possible, pediatric dentists manage anxiety without medications, but some children may require some type of sedation.
-
"Positive reinforcement" techniques can shape a child's behavior and attitude to accept dental treatment.
If a child has extensive dental disease and is unable to accept treatment in the office, general anesthesia in an operating room may be necessary.
Rubber dams
Once the local anesthesia and any sedation have been given, the dentist will put a rubber dam on your child's teeth. This is a piece of latex or latexlike material, about 5 or 6 inches square, that isolates the tooth that your dentist is treating. A hole is punched for the tooth and the dam is placed over the mouth so the tooth comes up through the hole. The rest of the mouth is protected by the sheet.
Most dams are latex, but some are made of other materials for children with latex allergies. Some rubber dams are scented or flavored.
The dam has several advantages:
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It protects the cheeks, tongue and lips and keeps them out of the way of the procedure.
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It keeps saliva away from the procedure. Most of the materials that dentists work with are more effective in a dry environment and in some cases saliva can weaken a filling.
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It prevents the child from accidentally swallowing or choking on anything during the procedure.
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It makes many children feel safer because the procedure feels less invasive with the rubber dam between the child and the dentist.
Removing decay and placing the filling
Almost all fillings are prepared using handpieces, or drills. A newer method of removing decay, air abrasion, can be used in certain circumstances, usually when preparing a tooth for a plastic filling. Air abrasion often can be used without local anesthesia and is very quick. However, very few dentists have air abrasion units, and even when air abrasion is used the dentist will often still need to use a drill.
The dentist uses the drill or air abrasion to remove the decayed tooth material and shape the tooth to receive a filling. If a plastic filling is being placed, the hole the dentist makes is etched with a weak acid gel for 15 or 20 seconds. This prepares the surface of the tooth so the plastic filling will bond to it.
The filling —
amalgam or plastic —
is placed in the tooth and allowed to harden for a few minutes. Plastic fillings must be placed in thin layers and each layer must be hardened with a special light before the next is placed. This is one reason why plastic fillings take longer than amalgam ones.
Once the filling has hardened, your dentist will smooth and polish it. He or she will remove the rubber dam and ask your child to bite down gently on a piece of special marking paper. This allows your dentist to make sure the filling has not disrupted the bite (the way the teeth come together). If the bite is not correct, the filling will be reshaped until it fits.
After The Procedure
Your child should experience minimal discomfort after a filling is placed. If discomfort occurs, it is usually because the tooth's pulp or the soft tissue around the tooth has been irritated. This discomfort usually goes away after the first 24 hours, so if your child complains of pain for several days, contact your dentist's office. Over-the-counter pain medications can be given to relieve discomfort.
The biggest concern after placing a filling in a child is that the child will accidentally chew, suck or bite on the anesthetized area while it is still numb. Children may suck or chew on a numbed lip because it feels like it's swollen. This can cause significant injury. Your dentist should warn you and your child about the numbed area so you can watch your child until the anesthesia wears off.
Feed your child only soft foods until the numbness goes away to avoid accidental bites on the lip or cheek. Besides this limitation, your child does not have to avoid any foods after receiving a filling.
If your child complains that his or her teeth don't come together right, or that it "
feels funny"
during biting or chewing, the filling may need to be reshaped. Contact the office to see if the dentist should check the filling. Sometimes, the filling will settle by itself over a few days.
Some local anesthetic injections can nick small blood vessels and cause bleeding under the skin. You may notice a slight swelling in the side of your child's face, or a black-and-blue area on the cheek. This happens only 3 percent to 5 percent of the time and does not require treatment. It is like any other simple bruise. You can put ice on the side of your child's face to bring down the swelling, and it should go away completely in a few days.
Long-Term Problems
A filling can fracture or crack. This is more likely to happen if the bite is not correct and too much pressure is placed on the filling.
Fillings also can leak, which means saliva and bacteria can seep under the filling if the filling doesn't fit tightly enough against the tooth structure. Leakage can cause sensitivity and further decay. It is more common in plastic fillings. Fillings also may fail if new decay starts.
It's important for your child to visit a dentist for an examination at least twice a year. During the examination, your child's dentist will check fillings to make sure they are still in place and are not leaking.
When Are Crowns Used In Primary Teeth?
A crown, which many people call a "
cap,"
is a cover placed over the entire tooth and is made to look like a tooth. It is used for teeth that are badly damaged or decayed. In children, crowns are used for a number of reasons.
It's important to try to save primary teeth until they are ready to fall out on their own. Primary teeth are important not only for cosmetic reasons, but also for chewing food and allowing speech development to proceed normally. The primary teeth also maintain a space for the permanent teeth and help to guide the permanent teeth into position.
If decayed primary teeth are not treated, the infection can spread in the mouth. Pain and infection can lead to other health problems as well.
Molars
Molars are the teeth in the back of the mouth used primarily for chewing. There are eight primary molars. Dentists will use a crown on children's primary molars in several cases:
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When a primary or young permanent tooth has extensive decay, often on three or more surfaces
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When a filling would be very large, because large fillings can weaken the tooth
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When a primary tooth has not developed normally
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In children who have high levels of decay, are disabled, or who have poor oral-hygiene habits (the crown will protect the tooth from further decay)
Front
The front teeth include the incisors and canines, which are used primarily for biting. There are four primary incisors and two primary canines in each jaw (upper and lower). Dentists place crowns on these front teeth when:
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There are large areas of decay on several surfaces
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The tooth has undergone root-canal therapy (endodontic therapy)
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The tooth has been fractured and part of it has been lost
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The tooth has a developmental defect
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The tooth is discolored and is cosmetically displeasing
Your child may need a crown even for a relatively small cavity in a primary tooth because primary teeth are smaller than permanent teeth and have thinner outer layers. A crown may be needed to strengthen the tooth and protect it from breaking or cracking.
Types Of Crowns
Pre-formed, stainless-steel crowns are the most common crowns used in primary teeth. They are manufactured as metal shells of varying sizes that can be customized to fit any tooth.
These crowns have been used in children for 50 years and are durable and relatively easy to place. Because a crown covers the entire tooth, it protects it from decay. Studies have shown that stainless-steel crowns are about half as likely as amalgam fillings to need replacement.
Other types of crowns used in children's teeth include:
-
Strip crowns, also called acid-etched resin crowns. These are made using a form that is filled with plastic material and placed over the tooth. The durability of a strip crown depends on how much tooth structure is left and how well the tooth was prepared before the crown is placed. Strip crowns take longer to place than stainless-steel crowns, but not as long as open-faced steel crowns. Trauma to the tooth can fracture, loosen or dislodge this type of crown.
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Open-faced steel crowns, in which the front area of the steel is cut away and replaced with tooth-colored plastic. These crowns are more cosmetically appealing than stainless-steel crowns, although some metal usually shows at the edges and on the back of the tooth. These crowns are very durable and stay in place well.
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Veneered steel crowns are steel crowns with a tooth-colored face bonded to the front. These crowns are cosmetically appealing and durable. However, the facings occasionally fracture or pop off.
Placing The Crown
In adults, crowns are placed during several visits, including one to take an impression and place a temporary cap, and another to fit the crown (usually gold or a semiprecious alloy) and cement it into place.
Unlike adults, children usually receive a crown during a single visit.
Local anesthesia
Your child will receive a topical anesthetic —
a gel or cream —
on a small area of the gum or inner cheek. Once the area is numb, the dentist will inject a local anesthetic, which will numb the area of the mouth where the crown will be placed for 1 to 3 hours.
Managing anxiety
Pediatric dentists focus on the care of the whole child, not just the child's teeth. Pediatric dentists can help ease a child's anxiety and cope with the difficult situation that a dental visit can be.
Some coping techniques include:
-
"
Tell, show, do "
—
the dentist tells a child what is about to happen, shows the child the instruments involved and what is going to happen, and then does it.
-
The dentist uses a soothing voice to calm a child.
-
Whenever possible, pediatric dentists manage anxiety without medications, but some children may require nitrous oxide or oral sedatives.
-
"Positive reinforcement" techniques can shape a child's behavior and attitude to accept dental treatment.
-
If a child has extensive dental disease, general anesthesia in an operating room may be necessary.
Rubber dams
Once the local anesthesia and any sedation have been given, the dentist will put a rubber dam on your child's teeth. This is a piece of latex or latexlike material about 5 or 6 inches square that isolates the tooth that your dentist is treating. A hole is punched for the tooth and the dam is placed over the mouth so the tooth comes up through the hole. The rest of the mouth is protected by the sheet. Most dams are latex, but some are made of other materials for children with latex allergies. Some rubber dams are scented or flavored.
The dam has several advantages:
-
It keeps the cheeks, tongue and lips out of the way of the procedure and protects them.
-
It keeps saliva away from the procedure. Most of the materials that dentists use are more effective in a dry environment, and in some cases saliva can weaken a filling.
-
It prevents the child from accidentally swallowing or choking on anything during the procedure.
-
It makes many children feel safer because the procedure feels less "
invasive"
with the rubber dam between the child and the dentist.
Removing decay and shaping the tooth
The dentist will use a drill, called a handpiece, to remove the decay and shape the tooth so the crown will fit over it. First, he or she will reduce the chewing surface of the tooth, and then the sides of the tooth that touch other teeth. Your dentist will place the smallest possible crown, but it must touch the neighboring teeth so these teeth do not drift out of proper alignment, and the bite (the way the teeth come together) must be maintained.
Once the tooth is prepared for the crown, the next steps depend on the type of crown your child is receiving. Your dentist will test any crown to make sure it fits the tooth, and then shape the crown to fit as closely as possible. In the case of a strip crown, your dentist will size and shape a mold (called a crown form) for the tooth.
Once a stainless steel or open-faced crown fits the tooth, it will be polished, filled with cement, and pushed into place on the tooth. For an open-faced crown, the front will be cut away and replaced with a tooth-colored material. If your child is receiving a strip crown, the tooth will be etched with a weak acid gel so the crown will bond to the tooth. The crown form will be filled with plastic material and seated on the tooth. The plastic is hardened by a special light. Once the plastic has hardened, the crown form is removed, leaving a tooth-shaped plastic crown behind.
When the crown is placed on the tooth, your dentist will remove any extra cement or plastic, rinse your child's mouth, and examine the tooth and surrounding tissues.
Finally, your dentist will make sure the bite is correct.
After The Procedure
Your child may experience some mild discomfort after a crown is placed. This usually occurs because the tooth's pulp or the soft tissues around the tooth have been irritated. This discomfort usually goes away after the first 24 hours, so if your child complains of pain for several days, contact your dentist's office. Over-the-counter pain medications can be given to relieve discomfort.
The biggest concern after placing a crown, or any treatment in which local anesthesia is used, is that the child will accidentally chew, suck or bite on the anesthetized area while it is still numb. Children may suck or chew on a numbed lip because it feels like it's swollen. This can cause significant injury because the child will not realize how hard he or she is biting or chewing. Your dentist should warn you and your child about the numbed area so you can watch your child until the anesthesia wears off. If your child injures his or her lip or cheek, keep the area clean, and it will heal on its own.
Feed your child only soft foods until the numbness goes away to avoid accidental bites on the lip or cheek. Besides this limitation, your child does not have to avoid any foods.
If your child complains that his or her teeth don't come together right, or that it "
feels funny"
during biting or chewing, the crown may need to be checked to make sure it is not higher than the other teeth. Some local anesthetic injections can nick small blood vessels and cause bleeding under the skin. You may notice a slight swelling in the side of your child's face, or a black-and-blue area on the cheek. This happens only 3 percent to 5 percent of the time and does not require medical treatment. You can put ice on the side of your child's face to bring down the swelling.
Potential Long-Term Problems
All of the following problems occur only rarely.
Stainless-steel crowns — The cement could wash out and the crown could become loose.
Strip crowns — These crowns can chip or fracture or become dislodged, especially after trauma to the tooth.
Open-faced steel crowns — The plastic face could chip, or the cement could wash out and dislodge the crown.
Veneered steel crowns — The veneer can chip or fall off, or the crown can become loose or fall off.
It's important for your child to visit a dentist for an examination at least twice a year. During the examination, your child's dentist will check the crown to make sure it is still in place and is not leaking.
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