What your child’s teeth might need, and what we would do instead

Fillings

A cavity is a hole in the tooth made by decay. A filling cleans the decay out and seals the hole, usually in one visit.

Most parents arrive picturing the drill and the noise. For a small cavity in a child who is settled, the visit is shorter and quieter than that picture. The area is numbed first, the decay is cleaned out, and a tooth-coloured material is packed in and set with a light. Your child eats normally the same day.

The part worth knowing is that not every dark spot is a cavity that needs drilling. Decay that has only softened the outer layer can sometimes be held where it is with fluoride and checked again at the next visit. Drilling a tooth cannot be undone, so the first question is whether this one needs it yet.

If your child has several cavities at once, we do not do them all in one sitting. We work in order of urgency, and we stop before your child has had enough.

Crowns for milk teeth

A crown is a cap that covers the whole tooth. It is used when so much of the tooth has gone that a filling would have nothing left to hold on to.

Parents usually arrive with one question: are the silver caps necessary? Often a crown is the more durable choice rather than the pushier one. Cochrane found moderate quality evidence that crowns work better than fillings for decayed back baby teeth, and that crowns fitted with the Hall technique, which needs no injection and no drilling, caused less discomfort and fewer abscesses than fillings.^[1]

The Hall technique is worth knowing by name. The crown is slipped over the tooth and sealed, with the decay left underneath and cut off from the sugar it feeds on. For a young or anxious child it can turn a long appointment into a short one.

On white crowns: the evidence comparing metal with white preformed crowns is very low quality, so nobody can honestly tell you which lasts better.^[1] Many parents prefer white on front teeth, and that is a reasonable choice made on appearance rather than on evidence. We fit either, and we will say which one we would pick for that particular tooth.

Baby root canal

When decay gets past the hard outer layers and reaches the nerve inside the tooth (the pulp), cleaning the cavity is no longer enough. The infected tissue is taken out, the space is filled, and the tooth is usually crowned afterwards so it holds together.

The question almost every parent asks is why bother with a tooth that falls out anyway. The answer is that it is not idle while it waits. It is holding the space for the adult tooth behind it, it is doing its share of the chewing, and an abscess under it sits directly above the adult tooth forming in the gum.

It is also worth saying plainly what this is not. A baby root canal is not the adult procedure of the same name. The nerve chamber in a milk tooth is smaller and the treatment is shorter.

Your child is numb throughout. Most of the pain parents are bracing for belongs to the infection rather than the treatment, and that is the part that settles once the tooth is cleaned out.

Silver diamine fluoride

Silver diamine fluoride is a liquid painted onto a cavity to stop it spreading. No drill, no injection, a few seconds per tooth. AAPD gives a conditional recommendation for 38% silver diamine fluoride to arrest cavities in milk teeth as part of a wider plan.^[2]

It turns the treated spot black, and that is permanent.^[2] Not grey, not dull. Black. We will show you a photograph of what that looks like before you agree, not after.

On a back tooth most families accept it easily, because nobody sees it. On a front tooth it is a real decision, and some parents say no. That is a fair answer and it does not change how we treat your child.

What it buys is time and calm. A two year old with four cavities cannot manage four appointments in a chair. Stopping the decay where it is means the repair work can happen later, in fewer visits, when your child is ready for it.

It is not a permanent repair. The hole is still there. It is stopped rather than filled, and it still needs restoring at some point.

Taking a milk tooth out

Sometimes a tooth cannot be saved. It has broken down past the point a crown would hold, or an infection will not settle, or it is loose and nearly due out anyway.

Taking it out is quicker than most parents expect. The area is numbed first, and what your child mostly feels is pressure rather than pain. The appointment is often over before the numbness has worn off.

Two things matter afterwards. The first is the socket: no hard rinsing, no straws, and soft cool food for the rest of the day. The second is the gap. A front milk tooth lost early is mostly a cosmetic gap, and the speech worry parents have usually settles on its own. A back milk tooth lost years before the adult one is due is a different situation, because the teeth either side drift into the space. That is what a space maintainer is for.

We would rather repair a tooth than remove it. A badly infected tooth that keeps flaring up is not worth three more attempts at saving.

Space maintainers

A space maintainer is a small fixed spacer, usually a band on one tooth with a wire across the gap. It holds the space open after a back milk tooth is lost early, so the neighbouring teeth do not drift in and block the adult tooth on its way.

It is a quiet piece of dentistry that prevents a loud one later. An adult tooth with nowhere to come through either stays trapped in the bone or arrives sideways, and both of those become an orthodontic problem at eleven that a small wire would have prevented at six.

It is cemented in, so there is nothing for your child to remember to wear. It feels strange for a day or two and then stops being noticed. Sticky sweets and chewing gum are the things that pull one loose.

Not every gap needs one. If the adult tooth is close behind and the X-ray shows it nearly ready, the space will not be open long enough to matter. We check rather than assume, and we check again at each visit, because it comes out once the adult tooth is ready.

Fluoride varnish

Fluoride varnish is painted onto the teeth in a few seconds, usually twice a year at the check-up. It sets on contact, tastes of very little, and your child can talk and walk out straight afterwards.

A Cochrane review found a substantial reduction in decay in both milk teeth and adult teeth, on moderate quality evidence.^[3] That is a strong result for something that costs very little and takes almost no time.

Parents sometimes ask whether it is safe, given everything said about fluoride online. The amount used is small, it is painted onto the tooth rather than swallowed, and it is applied here rather than left at home with your child. It is a different thing from swallowing fluoride supplements, which is where most of the online argument actually sits.

Soft food that evening, and skip the brushing that one night so it stays on the teeth while it works. Normal brushing the next morning.

Sealants

The biting surface of a back tooth is not flat. It has deep grooves, and on some children those grooves are narrower than a toothbrush bristle. A sealant is a thin coating that fills them in, so food and bacteria have nowhere to sit.

It goes on the first adult molars, which arrive around six years old, at the back behind the last milk tooth. Many parents do not notice they have come through, because nothing falls out to announce them.

There is no drilling and no injection. The tooth is cleaned, the coating is flowed into the grooves and set with a light. Your child eats normally straight after.

Sealants wear down. They get checked at every visit and topped up when they need it, which is a better outcome than the filling they prevented.

Check-ups and cleaning

A check-up is a look, a clean, a fluoride varnish, and a conversation about what is actually happening at home. Most visits find nothing. That is the point of coming, not a sign the visit was wasted.

Every six months is the usual rhythm, and more often if decay has already started or your child is in braces. The first visit should happen by the first birthday, or when the first tooth arrives, whichever comes first. That is earlier than most families expect.

The part that does the most work is the boring part. We will ask what your child drinks at night, how long the bottle or cup stays in, whether brushing is a fight, and who is holding the brush. Those answers change the advice more than anything we see in the mouth.

Waiting until something hurts is how a filling becomes a root canal. Pain is a late signal in a tooth. By the time a child complains, the decay has usually been working for months.

X-rays

A dental X-ray shows the two places we cannot see: between the teeth where they touch, and inside the bone where the adult teeth are still forming.

They are taken when there is a reason, not on a schedule. A reason is decay suspected between teeth that sit tight together, a tooth that has not arrived when it should have, an injury, or planning before a root canal or a space maintainer.

Parents ask about radiation, and it is a fair question. The dose from a small dental X-ray is low. Your child is covered with a lead apron and a thyroid collar, the beam is aimed at one small area, and the digital sensors used need less exposure than the film they replaced.

The comparison worth having is not an X-ray against nothing. It is a small image now against a cavity that goes unseen and becomes a root canal in a year.

Teething

Sore gums, dribbling, chewing on everything, a few unsettled nights. Teething is uncomfortable rather than dangerous, and it passes without treatment.

The first tooth usually shows up somewhere around six months, but the range is wide, and a late first tooth on its own is not a problem. The bottom front two generally come first.

Something cold to chew usually does more than anything from a tube. A clean chilled teething ring, a cold spoon, or a clean finger rubbed firmly on the gum. The firm pressure is the part that helps.

Two things to avoid: amber teething necklaces, which are a choking and strangulation risk, and letting your child fall asleep with anything sweet in the mouth. If you want to use a gel, ask us first, because not all of them are meant for babies.

A real fever, loose motions, refusing feeds, or a child who is genuinely unwell is not teething. Teething gets blamed for a good deal of illness it did not cause, and that delay is the actual risk. That needs a doctor rather than a dentist.