Understanding Tooth Decay in Children

    Why a child does or does not get cavities can sometimes be very baffling. This is such a complex disease that I think many factors need to be considered when determining the susceptibility of a child’s teeth to tooth decay. First let’s talk about children who don’t get cavities. There are a fortunate but very small group of people in our society who literally are immune to tooth decay. In discussions with the parents of these children it becomes apparent that neither of the parents has ever had a cavity. The child stays free of decay in spite of a poor diet, poor hygiene or not visiting a dentist. I think there may be a very effective genetic resistance to this disease. I know this is merely a hypothetical observation but I’ve seen it in enough children to believe that the genetics certainly is an important factor. I was also confounded when I found the child whose parents were rigorously careful about diet, home care, and had regular dental visits including fluoride varnish treatments but no matter what they did the child inevitably was going to get additional decay somewhere along the line. Honestly, I wish that I could determine the most important factor in the decay process. Children who experienced almost uncontrollable tooth decay seemed to have either one or both parents with serious dental problems and usually it would be related to the mother because of the more intimate contact. There’s no question in my mind that certain bacteria that are particularly instrumental in causing decay may well have variant strains capable of greater acid production.

     Are all streptococcus mutations and lactobacillus bacteria equally efficient in creating acid from starches and sugars? At the initial dental visit I felt it was important to discuss the dental history of the parents to help me understand susceptibility of the child to this disease. When a parent reported that both spouses have a long history of multiple dental problems it made it imperative for me to discuss how important preventive care was for their child. When the AAPD and the AAP began recommending that children see a dentist by one year of age, it presented the opportunity for me to observe very young children, most of them without tooth decay, and to observe that different children had noticeable variations in the amount of plaque on their teeth and the health of the gingiva. Certain bacteria begin to cultivate in the mouth simply as a result of the their presence in the environment. I recently learned that up to 80 million bacteria are spread with one french kiss. Other bacteria which I believe may be more instrumental in tooth decay may need multiple exposures to take a foothold in the baby’s mouth and begin to grow. When a mother came into the office with her child and I saw that she was pregnant with another child, I began counseling the mother about how to take care of the new baby after birth. I encouraged mothers not to share their bacteria with their baby; in other words, don’t let the baby put his hands in the mother’s mouth and then transfer those bacteria to his mouth. I tried to get the mother to understand that the bacteria that cause tooth decay should not be shared with the baby.

    We have all heard about the mother who takes the child to the mall and the child has a pacifier. The pacifier falls on the floor at the mall, mother picks up the pacifier, puts it in her mouth to quote “clean” it and sticks it back in the child’s mouth. I told mothers that putting the pacifier in her mouth coated the pacifier with more bacteria than the floor of the mall. I really couldn’t find any studies that supported the theory but it honestly was my belief that parents with serious dental problems absolutely should not share their bacteria with their children. Those were the families that I emphasized the importance of using antibacterial methods to help keep their child’s mouth clean. Mouth washes and toothbrushing were certainly a major part of this antibacterial program. For newborns I always told the parent that from day one, it is important after you feed your child, that when you wipe off his face, wipe out his mouth. The baby can’t tell the mother that there is an awful aftertaste to warm milk and just by watching a baby sucking on a cold washcloth after feeding, reinforced in my mind that the child needed and liked having a clean mouth. When the teeth began erupting it was important and effective to have the mother use the washcloth to gently clean the newly erupting teeth. This led me to a discussion of teething pain. Frequently I heard reports from a mother that the baby was very fussy, had a fever and a runny nose until the tooth came through and as soon as the tooth came through all of these things went away. I was baffled that with three children of my own, I never saw any of my kids experience teething pain. Were we just lucky that my children didn’t have this problem? In doing a little investigating, I found several things that were applicable to the issue. I came to the conclusion that the pain of teething was really not from the tooth erupting. In treating six-year-olds, I almost never heard a parent tell me, “yeah he had a terrible time getting his six year molars in”. This is the largest tooth that erupts into the mouth with no preceding deciduous tooth. Why did the tooth come in without causing the child some discomfort? In looking at the mouth of babies, what I saw was that when a tooth was erupting, especially like the first primary molar at 14 to 16 months of age, the tissue around the erupting tooth was very inflamed. I believe that the pain of teething really is an inflammation of the gingiva and not that the tooth cutting through that caused the pain.

    So how do we account for the fussiness in the six month old who was getting a lower incisor? I think it is well-established that a newborn carries the antibodies to many childhood illnesses from the mother thus protecting the child in the early months of life. As the child goes out into the world, he begins to be exposed to many things in the environment that lead to the child developing his own immune system and his own antibodies. It is coincidental with eruption, that around six months of age he may have a subclinical bacterial infection that causes crankiness, slight fever, malaise or whatever but it really is the subclinical infection that is responsible for the symptoms and not the eruption of the tooth. It is coincidental that the tooth is coming through at about the same time the child is developing this immune system and it is logical for the parent to assume that it was the tooth causing the pain and in reality, not understanding that the symptoms were a result of the hidden subclinical infection. Many of us remember the days in college studying long hours and not paying close attention to our dental hygiene that led to gingival discomfort, early gingival disease, bleeding gums etc. I think it is obvious that if we neglect our hygiene we will suffer uncomfortable consequences. I think the same thing happens in the baby. I think there is good research that tells us when the tooth first erupts it has not completed its calcification. I explained to the parent that calcium in the diet and application of fluoride varnish would contribute to helping the tooth to complete its calcification in formation and thus make the tooth more resistant to tooth decay. It seems to me that the two periods that are most important to providing good dental health over a lifetime are from six-month to two years of age and from six years of age until 13 years of age which are the periods when teeth are coming into the mouth. If we are particularly vigilant to provide good care and good preventive care to the child during those periods I think it allows the teeth to complete their calcification and become more and more resistant to this disease. As a parents myself to three children, I observed that we had a great influence on developing their taste preferences. There were so many things that we were unknowledgeable about as new parents that it never occurred to us to question how much sugar was in the baby food that we were giving our precious new child. When our second child came along a little more than a year later, not only were we more nutritionally conscious, but also cost-conscious and we found that many of the foods that we were giving the first child could easily be prepared at home with fresh ingredients and without all of the added sugar. Our second and third children from the onset consumed far less sugar in the early months of their lives and I believe that it affected them throughout childhood and even as adults today. The oldest child is still the most sugar craving while the younger two are both far less interested in sweet foods and have a much broader range of taste and likes ranging from spicy to sour to exotic.

    I think I would be willing to bet that families with children with no tooth decay would be families with far less sugar in their diet. We know for certain that the sugar in the diet is responsible and contributory to the amount of plaque that grows in a child’s mouth simply by providing the dextrans and biofilm on which the bacteria can grow. And now it makes sense that limiting the sugar, decreases the bacterial growth in the mouth and keeping the teeth clean removes the biofilm that is formed thus leading to reduced susceptibility to tooth decay. It is not just one of the other factors that needs to be controlled but both need to be controlled as part of the preventive program.