Cosmetic Dentistry Blog Cosmetic and General Dentistry Questions Answered

September 10, 2018

Using restraints in treating difficult children


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In my practice, I very much enjoyed seeing children—even children who were difficult to treat. Part of the reason for that was that the pediatric dentist on my side of town was someone I felt was mean and who would put ugly stainless steel crowns on front teeth, so I didn’t want to refer to him. But a big part of it was because I enjoyed the challenge of trying to understand each child and how to get them through the care that they needed.

One issue in providing dental treatment to children is the use of physical restraints. Sometimes it is needed, and I want to address two aspects of that restraint.

The first aspect is the use of a mouth prop to keep their mouth open anytime I was drilling on their teeth. When I was in dental school doing my rotation in the pediatric dentistry clinic, before I took my turn as the operator I did a turn as an assistant. My fellow dental student was doing a small, routine filling on a baby tooth when our patient bit down unexpectedly, poking the drill through to the pulp of his tooth. We had to call the instructor over and upgrade the treatment to a pulpotomy (the baby-tooth equivalent of a root canal treatment) and stainless steel crown. My partner got a lecture about using a mouth prop and I vowed in that moment that this would never happen to one of my patients—I would always use some type of mouth restraint.

I ended up routinely using a Molt mouth gag on all my child patients when I was using a drill on a back tooth. I never, during dental school or my 20+ years of private practice, had an accident like my dental school partner.

a scissors-like device with rubber prongs on one end to hold the mouth open and a ratchet to hold the position

The Molt mouth gag

But there was a very small minority of child patients that we would run into maybe once every couple of years that would need even more restraint to treat them safely. In spite of all the psychology we could use on them, they would thrash around with their arms and legs, making safe treatment impossible. When this would occur, I would excuse myself to the reception room and ask the parent for permission to physically restrain their child. They always gave permission, and we would proceed to wrap them in a papoose and complete the treatment.

a 6-year-old child wrapped tightly in a blanket, restraining his arms and legs

The Papoose Board

This technique has been criticized by some as being mean and traumatic to the child. That isn’t my experience at all. These were strong-willed children who refused to cooperate and were determined to make it impossible to fix their teeth; and without general anesthesia it would have been completely impossible to treat them. Once they fully realized that the treatment was going to go forward whether or not they chose to cooperate, they would completely calm down. I cannot remember an instance when that didn’t happen. Sometimes, having become physically worn out from their earlier resistance, they would actually fall asleep as the treatment proceeded.

Once treatment was done, we would unwrap them, congratulate them on finally settling down, give them their choice of toys from the prize box, and part friends.

– Dr. David Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

September 2, 2015

How about a flipper for my 2 1/2-year-old?

Dr. Hall,

My 2 1/2 year old had to have his two front teeth removed due to nerve damage from a fall. His dentist retired and we were sent to a new one. I mentioned a “flipper” or some sort of press-on cosmetic tooth (teeth). The dentist was slightly rude and told me, “he’s 2, he won’t cooperate for a flipper”. What is your opinion?
He has Medicaid so I’m going to assume that this wouldn’t be covered. The Do-It-Yourself kits online are all made for adults. Ughhh, I don’t want his teeth shifting and he’s already had to walk around like this for 10 months!
Any help would be greatly appreciated
-Kristine from Michigan

Kristine,

It’s unfortunate that your dentist was rude. However, as a parent who raised five children and one who had a lot of experience treating child dental patients, I can tell you that he is right. Not only would it be impossible to get a child of that age to understand the need to cooperate with wearing a flipper partial, there are other issues.

dental flipper partial

a flipper partial

It wouldn’t be safe, for one thing, as a flipper has the potential to come loose and choke your child. Just as you wouldn’t give your child certain toys with small parts or plastic bags that would pose a choking hazard, so you wouldn’t put something in their mouth that could easily come loose.
Besides this, there is a functional problem. A flipper is held in by metal clips or plastic parts that clip or press against other teeth. At that age where teeth are in development and the mouth is growing so quickly, you couldn’t get an appliance to stay in for any prolonged period of time.
However, there is good news in this situation, and that is that first, his baby teeth won’t shift at all because of missing front teeth. The shifting because of missing teeth in children occurs because of missing back teeth, and when those teeth are lost prematurely, a space maintainer is usually needed.
Second, children at this age are not self-conscious at all about missing teeth. So many children both younger and older have missing front teeth, either because their baby teeth haven’t come in yet, or they have lost baby teeth and are waiting for the permanent teeth to erupt. But even if that weren’t the case, I came to know several children who lost baby teeth due to accidents and it didn’t seem to faze them at all.
Bottom line–I wouldn’t worry about it.

Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

November 29, 2010

What is a pulpotomy?

Filed under: Children's dentistry — Tags: , , — mesasmiles @ 1:45 pm

hello i would like to ask about pulpotomy treatment for children..thank you.
– Yamir from Iraq

Dear Yamir,
A pulpotomy is done on an infected baby tooth to kill the infection. In this treatment, most of the pulp of the baby tooth is removed, down to the roots, and the tissue inside the roots is daubed with a disinfectant such as formocresol. The tooth is then sealed and usually covered with a stainless steel crown.

It’s kind of like a root canal treatment shortcut for baby teeth that will fall out in a few years anyway. It is usually done only on baby molars, because they need to stay in place until about age 10-12 in order to hold the space for the permanent premolars. If those teeth are lost too early, the permanent teeth will come in all jumbled – not a good situation.

Another treatment option, if the tooth is too infected, is to take out the baby molar and place a space maintainer.

If you’d like to read more, you can go to the page in our pediatric dentistry section about pulpotomy.

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

February 24, 2010

My 9-year-old daughter broke her front tooth.

Filed under: Children's dentistry,Traumatic Injury — mesasmiles @ 2:12 am

Dr. Hall,
Last night my daughter who is 9 fell and broke one upper front tooth and put a horizontal crack in the other. We took her to a dentist today and he doesn’t have the time to fix it until March. I want it fixed now and want to go somewhere else. He said the root needs time to desensitize anyway. Is it ok to bring her somewhere sooner or is it usual protocol to wait 3 weeks for a tooth to lose it’s sensitivity?

Thank you.
-Nicole from California

Nicole,
There is no reason to wait.

It will help if you have the piece that broke off. An excellent cosmetic dentist will be able to reattach that piece.

But I would strongly recommend choosing an expert cosmetic dentist from our list. You didn’t indicate what city in California you are in, or I might have recommended someone. But this is a tricky esthetic situation and you want this tooth to look good and match the other front tooth, and 98% of dentists wouldn’t be able to do that.

If you don’t have the piece of tooth to be reattached, I would recommend direct dental bonding as a repair for her broken front tooth, because of the age of your daughter. Then, when she is older and the pulp in the tooth is smaller, it may need a single crown, or more depending on exactly what the damage is on the other front tooth.
Dr. Hall

Read more about pediatric dentistry.
Read more about Preparing your child for a dental appointment

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

February 11, 2010

The teeth of my five-year-old are rotting.

Filed under: Children's dentistry — mesasmiles @ 4:32 pm

Dr. Hall, I had a question for you. I was doing research for my 5 year old daughter and her dental needs. She has 4 upper molars that need work done. Her two first molars have small cavities, but they are pretty deep. The two se! cond molars have both lost some tooth structure due to decay – I believe about 30% of the tooth is lost. My first question is: What is your take on this? I wanted to know what what I can do for this. I don’t want her two second molars pulled unless that is my only choice. She has stated that the 2nd molar on the right side hurts when she chews down on it. I want to thoroughly do my research before I send her to a pediatric dentist. Every single dentist she has had, she has not let them do any work on her mouth, which is why its escalated to this point. She will most likely have to be put under sedation to get this done. I am not sure if she needs white fillings, bonding, or onlays. How should I proceed? Thank you and have a great day.
Colleen from Brooklyn

Colleen,

At the age of 5, she has only baby teeth in her mouth, but those teeth are needed to help her eat now, and also to hold the spaces for the permanent teeth. If those teeth are lost, she will need space maintainers or her permanent molars will drift forward and crowd out her permanent teeth, and her mouth will end up being a huge mess.

So go with the sedation, if that’s what it takes to get this done.

Your care and concern for your daughter shows in your questions. Your daughter now has gotten to a point where she needs some tough love, maybe tougher than you’re used to. The reason children at this age get so many cavities is because of their frequency of eating. Decay of the type you are describing, at her age, requires constant feeding all day long. If you give in to every request for food or treats, this is the result. But if you let your daughter go hungry for three or four hours so she can build up enough appetite for a regular meal, and do that consistently, you will guide her into a more healthy eating pattern, and you won’t have to deal with recurring dental disasters like this. Otherwise, plan on going through this ordeal on a regular basis.

Dental work on baby teeth is usually geared toward short-term maintenance of those teeth, because the teeth will fall out around age ten to twelve. So when a large portion of a baby molar is missing, a dentist will usually place a stainless steel crown or some other type of prefabricated crown, which will cost considerably less and take much less time than the precision crowns that are made for adult teeth.

Dr. Hall

Related links:
Preparing your child for a dental appointment

We thank our advertisers who help fund this site.

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

October 26, 2009

Thumb sucking

Filed under: Children's dentistry — mesasmiles @ 6:01 pm

I was a thumbsucker up until I was 13. Now my teeth are shaped in a hideous way. I don’t have a typical overbite but my top teeth are shaped in an upward curve. I wish to know which procedure I need to go through to get my teeth fixed to the way they should be.
– Ellie in Trinidad

Ellie,
To correct the mal-alignment of your teeth after thumb sucking, you need to see an orthodontist. There are other possible options to make them look better, but from what you’re describing, the teeth are in the wrong position plus they have an incorrect inclination. Braces could solve both problems.

And, for the benefit of parents who see their children sucking their thumbs. My advice, after working with many parents on this issue during my dental career, and also working with my own children, is to play it cool. If you make too big an issue of it, you will actually reinforce the practice by creating a complex in your child. I would advise doing nothing until the child starts school. Thumb sucking causes no permanent harm when only the baby teeth are in, which is the case up until about age 7. And, if you “play it cool,” usually when the child starts school, peer pressure will help them quit. Notice that Ellie sucked her thumb until age 13. If she had quit when she was 7, she wouldn’t have had this problem.

If their permanent front teeth are coming in and they are still thumb sucking, you may need to intervene. But my warning is to use encouragement, not force, shaming, or other high-powered techniques, to avoid creating an emotionally complex issue for your child that could backfire. If your child finds the habit tough to break, there are aids that can help them break the habit. But they generally only work if the child wants to quit. If that is your child’s situation – they want to quit thumb sucking but find it is an ingrained habit, tell them you can help and buy Thum or another product to help them. Thum is a bitter liquid that you paint on the thumb. It makes thumb sucking unpleasant, and will help, provided you have not made it an adversarial situation with your child.

Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

October 5, 2009

Space Maintainer needed

Filed under: Children's dentistry — mesasmiles @ 5:59 pm

My 6 year old daughter has two broken baby teeth that are molars. The teeth have broken because of cavities/decay. The dentist we took her to is recommending that we extract the teeth immediately. Is this the right thing to do?
– Kristina from Wisconsin

Kristina,
When an adult tooth is infected, we do a root canal treatment. However, when a baby tooth is infected, root canal treatments rarely work, and never for baby molars, so the tooth has to be extracted. So your dentist is right to recommend they be taken out. The infection can spread in the bone and affect her developing permanent teeth.

You didn’t mention space maintainers. But I assume that your dentist is also recommending putting in one or two space maintainers, depending on which baby molars are involved. That is critical to prevent serious problems with her permanent teeth. At age six, her permanent first molars are either just about to erupt or have just erupted. They will drift forward and block out her permanent premolars, which could then erupt sideways or not at all. When baby canines and incisors are extracted, they don’t need space maintainers. But for baby molars, unless the patient is around ten to twelve years old (when the permanent premolars are erupting), they do. If your dentist hasn’t recommended that, you should find another dentist for your daughter.
– Dr. Hall

Related links:
Click here for basic information about pediatric dentistry.

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

March 29, 2008

Should I have my baby tooth extracted?

Filed under: Children's dentistry — mesasmiles @ 9:41 am

Dr. Hall,
I have baby tooth that won’t come out and there is another tooth pushing on it, and it’s coming out the side of my gums. It doesn’t hurt but my dentist says that he should pull it out. So this has me thinking about a few things.
1. What will happen if I do NOT get it pulled? and
2. Does it hurt to get a tooth pulled? I know that a numbing agent is used, but when they inject the agent, does the needle hurt (mind you I am terrified of needles)? I am 14 years old a pretty scared. Thank you for your time and any help would be appreciated.
– Amanda from Michigan

Amanda,
My you write well. You sound better and write more clearly than many adults who write to me.

If you don’t get this tooth extracted, you could make the permanent tooth crooked and you’d have to get that fixed with braces later. So you really should have it taken out. It’s so much easier to prevent these problems than to fix them later. Generally the rule is that if the permanent tooth starts to show in your mouth and the baby tooth hasn’t fallen out yet, that you should have the baby tooth extracted.

And generally when you have a baby tooth pulled that is just about to come out, it doesn’t take a lot of novocain. Most dentists will use a novocain ointment to numb the surface, and then they’ll give you the injection. Depending on the situation, and who the patient is and which tooth is coming out, sometimes the injection doesn’t hurt at all and sometimes it hurts a little. Sometimes the patient doesn’t even know they’re getting an injection. My best advice is not to think about it–that’s when it goes the best.

I hope this is helpful.
Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

March 30, 2007

Discolored baby teeth

Filed under: Children's dentistry — mesasmiles @ 3:39 am

Question:
My son (age 4) injured front teeth and have become discolored….is there any way they will regain original color? Anything I can do to help…diet?
Teri in Pennsylvania

Dear Teri,
Your son’s baby teeth are so small, there really isn’t anything practical to get their color back. Diet won’t have any effect. And they are already starting to lose their roots, if they are the very front teeth, and doing too much will make them grow loose prematurely. I’d advise just waiting until they’re ready to fall out. It’s probably only another two or three years before they fall out.
– Dr. Hall

We thank our advertisers who help fund this site.

About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

March 28, 2007

Baby teeth not falling out

Filed under: Children's dentistry — mesasmiles @ 4:41 pm

Dr. Hall –
My 6 year old has his second set of teeth that have come up but the baby teeth are still there and have not loosened up. Should I wait till they do loosen up or should he have them removed? I have not taken him to the dentist because I thought they would fall out on their own. Help what should I do???
– Mona from Michigan

Mona:
If you can see the permanent teeth coming in but the baby teeth haven’t fallen out, and you can’t jiggle them out yourself, I’d take your son to a dentist and have the dentist take them out. The baby teeth can deflect the permanent teeth if they’re not coming out the way they should.
– Dr. Hall

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About David A. Hall

Dr. David Hall was one of the first 40 accredited cosmetic dentists in the world. He practiced cosmetic dentistry in Iowa, and in 1990 earned his accreditation with the American Academy of Cosmetic Dentistry. He is now president of Infinity Dental Web, a company in Mesa, Arizona that does complete Internet marketing for dentists.

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