Dental Health in Early Childhood

By age two, most of the twenty primary teeth are in place, and the child should have been to the dentist at least once for an examination. Fluoride treatments will help to harden teeth against the ravages of children s diet and improper oral hygiene. Until about age seven, you should allow your child to brush correctly.

A Conversation With a Parent

I recall one parent, whose child had multiple cavities at every visit, telling me, “Dr. Bonnick. I do everything right with this child. I brush her teeth every night myself. She does not eat candies. My husband and I have decided not to buy snacks. I just don t know what to do?

She continued, “Well, Dr. Bonnick, it must be genetic. My whole family has soft teeth. It runs in the family. This dental thing is getting expensive, and I have three children. They all come here.”

I asked her, “When do you brush their teeth in the morning?”

She replied, “Dr. Bonnick, we are in a mad rush to get them to school. We are always running late; the kids hold us up. Do you have kids? Doesn’t everyone make their kids brush their teeth when they get up? Could their breath smell bad? We don t have time to brush after breakfast because we are rushing to get to school.”

I then asked, “When they get to school, do they brush?”

She replied, “They can’t brush in school. The teachers won’t allow them to brush in school. Aren’t they supposed to brush when they first get up?”

My response was that they should brush after eating to remove leftover food so the bacteria can starve. The rule is after any meal, snack, or drink (except water), all of us should brush our teeth.

This parent required her kids to brush twice a day — once when waking up and once before going to bed. By not brushing after meals, they wear plaque on their teeth for the rest of the day until bedtime. This is a prime scenario for cavities and gum disease to develop.

The parent mentioned that her school would not let their kids brush their teeth after lunch. She asked, “Would you give me a note for the teacher?”

“Absolutely, “ I replied. “If you have the children brush when they wake up, have them brush again after breakfast, and if they brush after lunch, they’ll be on their way to better oral health.” 

How Bacteria Grows On Your Child’s Teeth

It is incredible how many well-intentioned parents and teachers will tell the children to brush their teeth two times per day. The proper way to care for teeth and preserve them from the destruction of cavities is to brush within twenty minutes after each meal, drink, or snack.

As a dental student, I remember researching my senior project at the University of Maryland Dental School with a biochemistry professor. My job was to grow Streptococcus mutants (the most important bacteria to the creation of cavities in teeth) and study their adherence to smooth surfaces in different concentrations of sucrose similar to concentrations found in nature.

The goal was to determine how these bacteria stick to the smooth part of teeth and enable other bacteria to stick to the tooth surface. I obtained sugar cane juice from the government agency that quarantined it and found the sucrose concentration to be around 20 percent. I made up samples of 20 percent,10 percent, 5 percent, and 2.5 percent sucrose by diluting the sample with distilled water and used control samples of the same concentrations drawn up with pure sucrose(cane sugar) and distilled water.

My hypothesis assumed that adherence of the bacteria would be less with the natural juice than with pure sucrose. This unpublished study gave us two results: the bacteria had similar results to adherence between the pure sucrose and sugar cane juice, but surprisingly, the bacteria in the sample showed more adherences in the sample at 2.5 percent than at 20 percent (The bacteria glued themselves to a smooth surface easier at a lower concentration of sugar.).

The application of this knowledge to the mouth shows us that the bacteria’s activity is not that high at higher sugar concentrations. Still, as sugar in the mouth becomes more diluted with time, it promotes more adherences of Streptococcus mutants. So if you had fruit or some juice with sucrose and you did not brush right away, the lower concentration of sucrose (dilution) would make the bacteria more active (with time, bacteria sticks to teeth better) and cause more holes in your teeth.

Many parents are health-conscious, and sometimes it works to the detriment of their children. Some refuse to have their children drink fluoridated water, and instead, they use bottled or filtered water. These children not only lose the benefit of the hardening properties of fluoride when their teeth are developing, but they should use topical fluoride more often at a time when they are more likely to have dental cavities.

Care of Your Child’s Permanent Teeth

At approximately six years of age, the first permanent teeth start appearing in the mouth, and it is essential to have them sealed to protect them from cavities when children are not very good at cleaning their teeth. Baby teeth are often partially covered with gum tissue, and because it hurts to brush, some children neglect the proper cleansing of the area.

The first large back tooth is called the first molar. The first molar is one of the most important teeth for stabilizing the bite, and it usually appears when the child is six years old. It is the most important back tooth, and it represents the sweet spot for chewing.

The first molar is the tooth that is most often filled, extracted, or in need of root canal treatment because it is one of the first permanent teeth that appears in the child s mouth. Loss of the first molar is a common reason for posterior bite collapse (back teeth don t fit together well, so the bite is not as efficient as it could be). If it is lost, immediate replacement with an implant is of extreme importance.

The bone grows with the adult teeth’ eruption, and because of this continually growing as a child continues to grow, it is not a good idea to place an implant in the growing patient. Until the end of the growth spurt, bone development could change the relationship of the crown of the tooth with the developing bone.

Suppose a first molar or any primary tooth is lost early. In that case, have your child evaluated for a space maintainer (a device to maintain the space for an erupting tooth, prosthesis, or implant).

The mixed dentition stage is a confusing time for most parents. The primary teeth are being lost as permanent teeth are erupting into place, and the child is going through a growth spurt. Puberty gingivitis is common as hormonal changes, as well as poor flossing habits (non-flossing) by children, promote excessive plaque buildup.

Lack of flossing leads to more cavities between the teeth, so teeth sealed on top can still have cavities through the sides. Root canal treatments, as well as large fillings, are common during this time.

Your orthodontist will begin treatments during this transitional time for many reasons. Growth spurts can be used to correct malocclusions, and loss of teeth allows the orthodontist to move teeth into more ideal positions.

Levels of Occlusion

There are generally three classifications of occlusion (the way teeth come together). 

Class one occlusion is one in which the relationship between the upper and lower teeth is ideal. The upper teeth should be on the lower teeth cheek side, and the teeth relate correctly.

Class two occlusion is a relationship where the upper jaw and teeth stick out too far from the lower teeth, and the connection is one of a protruding upper jaw.

In a class three occlusion, the lower teeth stick out ahead of the upper teeth and give the appearance of a strong jaw. 

  • An overjet is not an abnormal condition. When the distance between the upper and lower front teeth is so far apart, it makes incising (biting) difficult or stresses the lower jaw to move extremely forward to touch the upper jaw. Overbites should be treated.
  • An overbite is the measurement of the upper front teeth closure over the lower. When an overbite is extreme, the lower teeth sometimes hit the upper gum near the mouth’s roof. Severe overbites should be corrected.
  • A crossbite can exist with one or more teeth when the upper teeth relationship is on the lower teeth tongue side. A slight overlap (degree) may not be harmful, but your dentist can determine whether it should be evaluated or not. A crossbite left untreated could result in facial deformities and improper development of one or both jawbones.

During the mixed dentition stage, the primary challenge is to get the child to brush after every meal and floss once or twice per day. The environment and parents attitudes set the tone for early-adulthood habits and determine how much it will cost for dental care in the future.



Implant Dentistry Guide – What You Should Know

Dental implants come in many various forms. There are subperiosteal implants, ramus frames, blades, and root form implants. A subperiosteal implant is used for areas where the bone is not sufficient to accommodate root form implants. Subperiosteal implants are also used in shrunken lower jaws. The ramus frame and blade implants are mostly used in the lower back jaw when the patient is not an ideal candidate for advanced bone grafting-techniques, or the doctor is proficient with this procedure and offers it as an option. The most common type of implants used most of the time are root-form implants that mimic the tooth’s root. The reasons given in this chapter are addressed primarily to the root form implant.

The implant consists of a titanium alloy that is biocompatible to the bone and encourages the bone to form around it, holding it in place. The healing process is referred to as osteointegration.

Once the implant becomes osteointegrated, it helps to preserve alveolar bone. Approximately 60 percent of the bone in your jaws grew in response to the erupting teeth. When a tooth is extracted, you go through a process of losing bone in that area that can last a lifetime. An implant helps to preserve this bone structure by slowing down the shrinkage. It also helps to prevent malocclusion. When you lose a back tooth, you set up shifting in the other teeth. Teeth adjacent tend to move into space, and the teeth opposing drift up or down into the newly formed space. Some spaces become food traps and contribute to bad breath and periodontal disease.

Implants can slow facial atrophy- shrinkage which occurs in facial muscles when they are not adequately exercised. Roughly 150 newtons of force are applied on normally functioning back teeth, while only 50 newtons are applied on the front teeth. This force keeps the facial muscles toned and maintains our looks. If missing teeth are replaced with implants, this force is restored, and good facial muscle tone is preserved. Additionally, the ability to chew correctly vastly improves the digestion process.

Teeth are more efficient at chewing than dentures, sometimes two or three times more. There is an increased risk of aspiration of food if you have false teeth. Aspiration of food is one of the causes of death in the elderly that hardly gets mentioned, except in CPR courses. To keep false teeth more stable, many denture users will place denture adhesive inside their dentures to help keep them in place. In America, about $148 million is spent on denture adhesives every year.

Complete lower dentures usually move about ten to twelve millimeters during chewing and contribute to the need to chew softer foods that may be less nutritious. Many denture wearers develop anti-social tendencies because of their limited ability to chew a wide variety of foods. Many are unwilling or are uncomfortable when they go out for a meal.

Dental implants will stabilize dentures, crowns, and bridges and allow for more efficient and confident chewing.

Many general dentists in the United States of America do not surgically place implants, although many advertise one of their services to be dental implants. What they mean is they will plan and restore your implant after a specialist surgically placed the implant. When I did it this way twenty years ago, the disadvantage is that if the patient had a problem with the implant, they did not have a direct recourse with one dentist. A concern for the patient is when the restoring doctor and the specialist disagree on who should take responsibility for defective materials or accidental damage to the implant. I have found that most good dental teams are willing to help the patient restore their dentition by redoing the work at a reduced fee.

Note: The patient’s responsibility is to keep the information on the size and make of the implant if the patient relocates or their dentist(s) retire, leave the practice, or change locations.

In the long run, implants are the most cost-effective and efficient option. Some patients choose bridgework to restore dentition because they lack the bone needed for an implant or think this is a less costly option. However, when a dentist prepares one tooth for a crown,’ the chances of needing a root canal is about 3-5% in five years. When at least two teeth are prepared for a three-unit bridge, it increases the odds of needing a root canal over the next five years from 3 percent to about 15 percent. The additional cost and the possibility of needing to redo your bridge after root canal treatment could end up costing you more than you thought you were saving over the cost of doing an implant. Cost is measured in money, but more costly is the inconvenience and time away from your other activities.

Did Grandma die early because she did not have implants?

In 1999 my grandmother passed away at the age of seventy-nine on the way to work. She was a firm believer that If you are not sick, you should have a job. She also had a great sense of adventure and often accompanied me on my mission dental trips or visiting another state or country. Although we had arranged for her to live with my mom and dad, she insisted on turning her key in her door.

Like many those born in the 1920s, Grandma got her dentures by the time she was forty years old, and like a lot of people, she did not like her bottom denture because it had no suction. I was not insistent on her having implants because she wanted to save her money to support her independence. In retrospect, this might not have been the best long-term decision because not having implants meant she could not crush her food correctly to receive the best nutrition. Studies show that dentures are about 30 percent efficient at crushing food, implant-supported dentures around 70 percent, and natural teeth around 90 percent.

Grandma complained about the loss of appetite, stomach pains, and irregular bowel movements. She had a medication that needed to be taken with meals to prevent further stomach irritation. On that fateful morning, her lack of appetite meant she did not eat to take her medication, and her increased blood pressure led to a stroke from which she did not regain consciousness.

I miss my grandmother and wish I could have done more for her. I have committed myself and my practice to promoting the benefits of having dental implants because I think it can make a difference in people’s lives. No amount of money saved was able to keep Grandma with us for additional years, but money invested correctly in making sure she could eat more than soups and mush might have given me additional years with her.

If you are missing some teeth and your dentist suggests implants, you should consider it a good option. Listen with an open mind. My Grandma would have wanted me to give you the option of implants, and I hope you agree.

Evaluating the Bone

As soon as a tooth is extracted, blood forms a clot in the socket, and new bone cells migrate into the socket area, accompanied by immune cells and cells that form supporting tissues. Remodeling leads to the formation of new hard and soft tissue.

At initial healing, the most significant amount of bone loss occurs at the extraction site, and then bone-loss slows but continues gradually over the years. The jawbone is composed of alveolar and base bone. Alveolar bone forms in response to the erupting teeth and starts to go away when the tooth is lost. Base bone provides the foundation on which the alveolar bone develops.

When we look at the series of pictures of an edentulous jawbone (a jawbone without teeth) over time, we notice that bone loss progresses after losing a tooth and can be accelerated when pressure is placed on the tissue by wearing a denture. We recommend that implants be placed, preferably after the extraction sockets are grafted.

People wearing any type of denture should be evaluated for implants. The national standard of care recommends that if you wear a complete lower denture, you should have at least two implants for lateral stabilization and more, if possible, for bone preservation.

People are living longer, and they will need to preserve their oral structures longer. The loss of even one strategic tooth could make for long and miserable golden years. After all, what are the golden years like without the ability to chew, digest, and receive proper nutrition

The same principle of implanting new teeth for accident victims or people born with congenitally missing teeth applies. Congenitally missing teeth is a condition where the patient has fewer than a full complement of teeth. With recent advancements in implants, it is getting easier to find an implant to replace the missing teeth.


Any implant with a diameter less than three millimeters is considered a mini-implant. An implant needs to be surrounded by bone if it is to have the best chance of surviving over a long time. Historically, many implants were small because patients had lost bone due to extractions and/or wearing fixed or removable dentures.

As the ability to grow (graft ) new bone has increased, the need for smaller implants may decrease. Initially, smaller implants were considered temporary implants to stabilize temporary teeth until the larger implants could integrate with the bone. The mini-implants were then removed, and new dentures were attached to the larger implants.

Today the technology for mini-implants is so good. We are finding that you can place the implant and, on the same day, attach the patient denture crown or bridge and have a high degree of success. Several years ago, I started to use the best of both worlds. I would place mini-implants while I placed standard implants and attached the denture to the minis while letting the larger implants integrate. In many of the cases we completed, we found that the minis’ aggressive threads that allowed you to use them right away, along with the latest technology and surfaces, made it difficult to remove the minis, so we incorporated them into the final prostheses (dentures).

Suppose a patient had a well-fitting lower denture that moved during chewing and did not want to wait four to six months until their implants integrated. In that case, they could have an initial evaluation and the necessary diagnostic X-rays and/or CT scan so they could be sized based on the remaining jawbone for implants. On the day of the surgery, they could be pretty confident that they would leave with an implanted denture with some degree of stability.

The Sterngold Company, a longtime manufacturer of attachments for dentures and crowns, came up with their version using mini-implants with conventional implants adapted to work with their ERA (Extra-coronal Resilient Attachment) system that allows the prosthesis a small range of movement and enhances their longevity. A rigid attachment puts a lot more force on the implants than a resilient attachment, and replacing the resilient part of the attachment is an advantage of the ERA system.

The Zimmer dental company has since bought this system. Implant Direct also manufactures a similar system that already has the attachment for the popular locator attachment.

If you could see a series of models of the lower jawbone just before and after teeth were lost, you would see a consistent pattern. Initially, the jawbone is at its maximum height and width and supports the patient’s facial features very well.

When a tooth is extracted, the alveolar bone that grew in response to the erupting tooth starts to shrink also. When the first denture is made, it is usually the best, because most of the alveolar bone is there for support; however, as bone loss continues, the denture sinks further into the soft tissue, and the height of the lower face contracts, giving the patient an aged appearance. The next denture should be made larger to compensate for the shrinking bone. But when the dentist does this, the patient usually complains because they slowly adapted to the first denture over time.

At that point, the dentist usually cuts back the new denture so it could feel like the first denture, except it does not feel as secure because some of the bone was lost. This bone loss continues until the jawbone’s nerve is close to the surface and causes the denture wearer discomfort.

At that point, the patient usually suffers from one denture after another, looking for a dentist who could give them the feel of their first denture. The way to slow this bone loss and aged look are to place socket grafts and/or implants as soon after extraction as is possible because alveolar bone stays around implants as if it was the root of a tooth. In effect, implants only help to retain dentures but help to maintain as well.

What Are Combination Cases

Our office prides itself in our ability to take care of multiple problems in a reasonable period, with or without sedation. Over the last few years, we had several cases that involved sinus surgery. With our current technologies, we can assess the amount of bone in the upper jaw before we encounter the sinus membrane. The sinus membrane is very forgiving and can repair itself in six weeks. If there is enough bone, seven millimeters or more, we can use blunt instruments to lift the membrane-like a blanket and insert bone grafting before placing the implant. If the amount of bone left is seven millimeters or less, I may elect a two-stage technique.

In the two-stage technique, bone is grafted below the sinus by displacing the membrane upward through a small hole made in the bone’s side. A collagen liner then protects the membrane, and a bone graft is packed, leading to a new bone growth of ten to twenty millimeters. Six months later, implants of varying lengths are placed and allowed to integrate as the grafted bone continues to mature.

After integration of the implants, implant-supported teeth are placed. The patient does not go without teeth because they wear a transitional prosthesis (temporary dentures or bridges) while waiting on the body to heal. We use several implant systems in our office, depending on the results we are trying to achieve. Sometimes we have to do extractions, bone graft s, root canals, fillings, or gum treatments; place implants or place transitional appliances all during the same visit. If the case warrants it, we can use mini-implants to hold initial devices securely until the long-term implants heal. A lot of prior planning goes into providing these treatments for combination cases.

Some patients who live a long distance from the office or even in another state can have a CT scan made, and the results emailed to us to do the virtual surgery and have all the supplies needed to perform the procedures before they arrive at our office.