When I heard the news, I felt that all-too-common parental emotion: I was a bad mother.
My 5-year-old daughter had cavities, explained the paediatric dentist. Multiple cavities, including one that had caused so much decay that a bottom left molar would probably have to be extracted.
I felt at fault, yet defensive. “We don’t let her drink a lot of juice,” I said. “We brush her teeth regularly, and she’s been seeing our family dentist since she was 2 1/2.”
Not flossing sufficiently, he explained, was probably the reason; the cavities began between her teeth. As soon as one develops, it can spread quickly throughout the mouth.
Our daughter, Nora, could have her cavities filled and the extraction done in his office over three or four visits, using anaesthetic shots and possibly nitrous oxide. But given the amount of work necessary, the dentist recommended doing it all at once after placing her under general anaesthesia at our children’s hospital in New Haven, Connecticut, and completing the work in one day.
“Like when you have an operation?” I asked, shocked. Twenty minutes earlier, my daughter had been a happy and healthy kindergartner. Now, I was discussing a hospital procedure for her.
The idea behind the hospital option was to ensure that Nora’s behaviour didn’t deteriorate over multiple visits — after a first round of shots, drilling and fillings, she was likely to hate coming back — and that she didn’t develop a negative relationship with him. “I want her to like me,” he said.
“Really?” I said to myself. “Maybe you shouldn’t have become a dentist.”
After the appointment, my guilt dispersed as annoyance took over. I’d never heard of using general anaesthesia for dental work, and worse, I felt as if I didn’t have a choice in the matter. The dentist had given me options, but his preference seemed clear.
He’d seen many parents come to regret getting multiple cavities filled in the office, he said, watching their children struggle and eventually refuse treatment. As we walked out the door, the receptionist gave me a brochure about surgery at the children’s hospital. I felt bullied.
Thus began my crusade: why, I wanted to know, was such aggressive treatment, along with the worry and risk associated with anaesthesia, necessary for baby teeth that would eventually fall out?
And what about this idea, promulgated by many paediatric dentists, that children should see a dentist by their first birthday?
“They barely even have any teeth at that point,” I exclaimed, commandeering the conversation over coffee dates with friends following Nora’s visit. “If she had a ruptured appendix, of course we’d go to the hospital. But for cavities?”
Fellow parents concurred, including my mother. “I don’t think I even took you to the dentist until you were at least six,” my mother told me after one of my rants.
It seemed unnecessarily intrusive and expensive, leaving small patients — and their parents — getting the raw end of the deal. An estimate for Nora’s dental work was more than $2,000 (Dh7,346), including $500 for anaesthesia and other fees if we chose to have the work done in a hospital.
But was I right? Spurred by my daughter’s situation, I decided to do some reporting. What I discovered was more complicated than I expected.
For starters, cavities in young children are not that uncommon. By age 5, about 60 per cent of US children will have experienced tooth decay, according to the “State of Little Teeth Report”, a 2014 American Academy of Pediatric Dentists document based on a survey of 1,000 parents. The report found that the rate of cavities in children 2 to 5 years old increased almost 17 per cent from 1988-94 to 1999-2004.
The report goes on to explain that tooth decay, particularly if left untreated, can result in infection, chewing difficulty and even malnutrition. If the decay is bad enough, abscesses may develop, affecting the health of the child’s permanent teeth.
There are significant socioeconomic factors at play: the “Little Teeth” report states that children 2 to 9 years old who are living in poverty are twice as likely to have tooth decay as are more-affluent children and that their cavities are more than twice as likely to remain untreated.
Because of the health problems that paediatric cavities can quickly cause, age 2 is no longer considered too early to bring your child to the dentist; many paediatric dentists recommend coming when the first teeth appear or by the child’s first birthday, whichever occurs first.
Ed Moody, president of the paediatric dentist group, said that historically the thinking had been to schedule a child’s first dental visit by the preschool years. But a toddler with a mouthful of cavities is a problem. “The worst case is when you’ve got them in on the first trip and you have to do something really big and it takes a long time to work through,” he said.
But why treat them, I prompted? These aren’t permanent teeth, right?
Moody, a dentist who practises in eastern Tennessee, gets this question regularly from parents.
Bottom line, he said, is that tooth decay is disease. Baby front teeth stick around until around age 6. Baby molars are there even longer, until around 10. So a child who has cavities at 2 could face years of pain and associated issues, such as trouble eating and concentrating in school.
Seeing children — and, more important, parents — early is the perfect time to talk about habits that can lead to decay, like frequent juice drinking, sugary snacks and putting babies to bed with a bottle.
Moody said that there is some luck at play regarding cavities, such as how widely spaced an individual’s teeth are (which may explain why Nora had so many cavities and my sweets-loving 3-year-old son has none).
So what is the best way to deal with decay in baby teeth? This is a subject of much debate.
General anaesthesia is a “tool in our toolbox” that can be crucial when a very young child, such as mine or even younger, has significant decay and won’t tolerate treatment while awake, said Bina Katechia of the University of Connecticut School of Dental Medicine’s department of paediatric dentistry.
But “it’s not something we jump to,” she said, because using general anaesthesia in the hospital can be time-consuming. “We can be so much more productive in the office.”
Charlie Coulter, a paediatric dentist in Washington, says that his office is “a little more lenient” than some of his colleagues about when a first visit should be. He and his partner, Dana Greenwald, often see children for their first dental cleaning at age 3, and that’s early enough for many — “although we’re happy to see patients at age 1,” he said. “We call those our ‘happy visits’” to discuss good nutrition and tooth-cleaning techniques and to acclimate a child. Everybody should brush at least twice a day, Coulter said, starting fluoride toothpaste when a child is able to rinse and spit on his own.
Coulter said he often chooses to observe rather than treat a cavity in a baby tooth that is likely to fall out in a year or less.
For minor cavities that will eventually need to be filled, he might try delaying tactics — for example, using a topical fluoride that can help protect tooth enamel from bacteria while slowing the progress of early tooth decay. Further treatment would be postponed until the child is a bit older.
Coulter isn’t averse to sedation such as nitrous oxide or general anaesthesia when necessary, but heading to the operating room is the last resort, he said.
No matter the treatment, the goal is taking it slow so that children don’t get scared. “At the end of the day,” he said, “our job is to get the children comfortable in the dental office, so they’ll come in every six months for the rest of their life.”
That seemed like a good goal to me. For my daughter’s cavities, we didn’t end up in the hospital with general anaesthesia. Instead, Nora had her cavities filled and one tooth extracted during four office visits. Nitrous oxide soothed her nerves and a few shots of local anaesthetic numbed the pain, while the dentist and a hygienist calmly explained every step of the process.
I decided that due to Nora’s age and absolute respect for authority, she could handle the in-office treatment. Parents usually know their children best, and I’m glad I questioned my dentist’s initial impulse.
She did fine. So did I.
Now 6, Nora has lost a couple of teeth, sturdy adult versions taking their place. We are taking very good care of them.
–Washington Post
Cara McDonough is a freelance writer who focuses on parenting and family life.
