Pediatricians advise parents of young children that they should manage cavity prevention as they would battle any chronic illness

By Neena Santija
Globe Correspondent / August 22, 2011

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‘Even a pediatrician can screw up,’’ says Dr. Michelle Dalal sheepishly as she recalls her young daughter’s first dentist appointment.

A pediatrician at Tri-River Family Health Center in Uxbridge, Dalal always thought she took good care of her child’s teeth, brushing them twice a day and limiting sweet snacks. So she was stunned to discover several cavities at her 3-year-old’s checkup.

“I was floored,’’ Dalal said. “I was almost in tears.’’ It cost more than $1,000 - with insurance - to get the teeth fixed.

While cavities are on the decline in the general population, they are a fact of life for increasing numbers of young children, according to the Centers for Disease Control. They affect 10 percent of 2-year-olds and over half of 5-year-olds, causing everything from minor toothaches to missed school days to complications that require major surgery. But dentists say few people realize that cavities are symptoms of dental caries, the most common chronic disease in children today, according to the CDC.

Caries is caused by a transmissible bacteria that produces acids in the mouth when we eat anything with carbohydrates, including sugary or starchy foods. Those acids dissolve the teeth, and without good oral health practices, they can lead to tooth decay - cavities. But cavities are preventable if the underlying caries is managed.

“Because it’s chronic, and because it’s a condition that is caused by bacteria, you can actually, as a patient, stop the disease process if you know what to do,’’ said Dr. Man Wai Ng, a pediatric dentist at Children’s Hospital Boston. “And you can actually prevent it from starting.’’

Ali and Jeannette Wicks-Lim weren’t aware of that when they brought their toddler, Mason, to the dentist for the first time after noticing signs of decay on one of his upper teeth. “I think it had almost started to look chipped,’’ Ali Wicks-Lim said.

They were shocked to find he had eight cavities. They never gave him candy or soda, and they brushed his teeth twice a day.

Dentists usually can’t fill very young patients’ cavities in the office because the children aren’t able to cooperate; their teeth must be fixed in the operating room. So the dentist in the Wicks-Lims’ hometown of Amherst recommended Mason for dental surgery at Children’s Hospital Boston.

But surgery to remove the teeth wouldn’t address the bacteria imbalance in his mouth - meaning that the caries would remain and new cavities would continue to form.

Dr. Burton Edelstein, a professor of dentistry and health policy management at Columbia University, likened the situation to “fitting a diabetic who’s lost a leg with a prosthetic leg. . . . The prosthesis does not treat the diabetes. And if you don’t treat the diabetes you’re going to lose another limb.’’

Edelstein helped develop the protocol Ng uses in her clinic, which she persuaded the Wicks-Lims to try instead of surgery when Mason arrived at the hospital in 2007.

She saw the family in her office seven times that year to apply Mason’s fluoride varnish treatments and counsel the parents on oral health practices.

It turned out that even though Mason’s parents were brushing his teeth regularly and limiting sugary snacks, he needed to do more because he was at higher risk for the disease.

Cavities seem to run in families, and both Mason’s parents had cavities as kids. Also, Mason wasn’t drinking water or using toothpaste with fluoride, an additive that creates a protective coating around teeth so that acid produced by caries-causing bacteria can’t weaken them as easily.

Mason may not have been eating sugary snacks, but he was eating crackers throughout the day. Because he wasn’t brushing his teeth after each snack, the constant presence of carbohydrates in his mouth fueled the bacteria and acid production.

After the Wicks-Lims visited Ng’s office, Mason started using fluoridated toothpaste; he avoided snacking between mealtimes and stopped eating raisins and gummies; and when he was old enough, he chewed on xylitol gum. Xylitol is a natural sugar that has been shown to fight cavities.

By the time Mason turned 3, he was old enough to get his front teeth restored without a trip to the operating room. And some of the cavities didn’t even require any kind of surgical treatment.

Now, he has two new molars and two new bottom teeth. “And they look great,’’ Ali Wicks-Lim said. “He’s always walked out [of the dentist’s office] happy.’’

In the case of Dalal’s daughter, a major culprit was nighttime breastfeeding. The flow of saliva that protects teeth is limited during sleep, making them particularly susceptible to decay.

“This is not rocket science. We’re talking about very simple things,’’ Ng said. And yet, “every time I talk to a new family . . . no one has ever talked to them about the causes of cavities.’’

Although we aren’t born with the bacteria that causes caries, most kids will get it at some point - by sharing a lollipop or a drink with a classmate, for instance. But the later they get the bacteria, the less likely they are to develop severe caries.

That means caregivers who have ever had cavities should take simple precautions with their babies. They shouldn’t put a baby’s spoon or pacifier in their own mouths before giving it to the baby, for instance.

They should also take children to the dentist before age 1 to determine their risk factors for caries, according to the American Academy of Pediatrics.

It may not be easy to find a dentist who will see kids that young, since dental practices often don’t get reimbursed for nonsurgical treatment techniques like counseling. So for many parents, the best option is to go through a pediatrician.

Ng is able to do more “dental therapy’’ work because of funding from DentaQuest Institute, a Boston-based nonprofit that works with dental providers to improve care. DentaQuest also put in place a similar evidence-based disease management protocol at St. Joseph Hospital in Providence, and has since expanded the model to community health organizations and other hospital residency programs.

So far, the results of the approach have been promising. DentaQuest reported that over a 30-month period, children in the program experienced fewer toothaches and had fewer visits for surgical procedures in the operating room under general anesthesia than those who were not in the program, resulting in more than $800,000 saved in medical charges.

“You’re such a good helper,’’ Ng told Mason as he obediently opened his mouth during a recent visit. At the same time, she was asking his parents what he drinks when he’s thirsty and what kinds of snacks he gets at school.

Asked whether he enjoys going to the dentist, Mason answered, “Kind of.’’

Maybe not as exhilarating as a trip to the candy store - but it’s a start.

Contact Neena Satija at

Care for kids’ teeth Schedule your child for a dental checkup before the first birthday. If you can’t find a dentist who will take a child that young, talk to your pediatrician. Even before your infant has teeth, clean his or her mouth with a wet cloth after feeding. That way, tooth-brushing will seem like a normal routine when the time comes. Don’t send your child to bed with a bottle or sippy cup that has anything other than water. As children get older, offer only water if they wake up in the middle of the night. Brush your child’s teeth with fluoride toothpaste twice a day. Remember that it’s safe to use fluoride toothpaste even if your child is too young to spit—just use a half-pea-size amount for each cleaning. Limit sugary foods and drinks. These include such seemingly healthy choices as fruit juice, raisins, and chewy fruit snacks. Don’t let your child get into the habit of grazing, or snacking on food all day long, even if the food is healthy or eaten in small amounts.

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