This is certainly so with cavities in teeth – they hardly ever go away, if we just wait, even though we might at times be tempted to believe that.

Fortunately most parents of small children are eager to handle any cavities they discover in their children’s teeth. But these teeth are often so small and cavities can not be easily discovered by the naked eye, especially if they develop between teeth – and flossing the teeth of a four-year old is not an easy task.

An additional factor in baby teeth is that cavities can develop rather quickly and virtually undetectable under the enamel. Only when this fragile outer shell collapses do they become obvious.

This might then look like this baby molar…

Decayed Primary Tooth: A cavity in a baby molar will look like this only if it is advanced. At this stage it has probably invaded the nerve (pulp) chamber and is in need of a laser pulpotomy.

If this is a tooth that would fall out very soon it could be removed to save the child from any possible tooth ache, but if this tooth is still needed to keep the space open for the permanent tooth to grow into, it need to be saved. Extracting the tooth and then using a spacer to maintain the opening for the new tooth would probably the more costly and way more inconvenient solution.

If we are in the fortunate situation that the majority of the pulp and nerve are still savable, a pulpotomy can be performed (see the graphical explanation).

The following sequence of images shows how this procedure is performed.

1. Decay has been cleaned out with a slow electric drill. There is bleeding from the gums as well as the nerve, which is exposed.

2. The tooth is sealed from the side with a "matrix" to prevent any blood or saliva creeping into the cavity during the following steps.

3. Laser energy is used to remove the nerve tissue from the pulp chamber (Waterlase at 2.25 W).

4. The laser is angled to completely remove nerve tissue from all the recesses of the chamber, to avoid future re-infection.

5. The openings into the canal are now visible with healthy and untraumatized nerve tissue left intact. Mild bleeding is very normal and indicates healthy tissue.

6. A mild 2-3% hydrogen peroxide solution is used to gently disinfect the chamber and stop bleeding before placing the MTA.

7. MTA (Mineral Trioxide Aggregate), a highly biocompatible cement is used to plug the openings to the canals. Very light pressure with a small cotton pellet is used to compact and dry it to avoid trauma to the nerve.

8. After making sure that there is no bleeding seeping through the MTA, this is now covered with a base of glass-ionomer cement.

9. After the Glass-ionomer sets in 5 minutes, traces of MTA and cement lining the side walls and the margins are removed with a dry, slow bur. A self-etching bonding agent is applied with a micro-brush and dried after 30 seconds.

10. The cavity is now restored with a bonded composite using proper bonding principles.

11. The final filling completed and polished. This tooth will survive for a few years until it is replaced with a permanent premolar.

The following graphics by Dr. Sarkissian show this development and the treatment of this condition. A permanent tooth would require a root canal treatment at this stage, but for a primary tooth a laser pulpotomy is indicated which keeps the tooth alive.

1. A healthy baby tooth (primary molar). The nerve (pulp) makes up a significant portion of its interior.

2. A true cavity arises when the outer enamel shell of the tooth is penetrated and bacteria invade the interior dentin layer of the tooth.

3. The cavity spreads at a rapid rate.

4. The bacteria have approached the pulp and start causing mild inflammation.

5. Due to softening of the befallen dentin, the outer shell crumbles and exposes the cavity. This is when most parents realize that their child has a cavity.

6. Laser Pulpotomy treatment is initiated. The cavity is excavated with an electric drill.

7. The Waterlase is used to remove, or amputate, the pulp from the chamber. There is no mechanical trauma, heat, or contamination. Hydrokinetic energy is used to break up the tissue without the tearing, crushing and smearing associated with the drill.

8. After mild irrigation with hydrogen peroxide and after bleeding has stopped, MTA (Mineral Trioxide Aggregate) is used to cover and seal the exposed nerves leading into the canals.

9. A glass ionomer cement is used to cover the MTA to allow for undisturbed setting and to prevent its contamination during the multiple bonding steps.

10. The tooth is bonded with resin composite employing the latest techniques in adhesive dentistry.

You can read the article about a real-world pulpotomy to see this procedure performed on a child’s primary molar.

You can find more information on Dr. Sarkissian’s web site under
Services ->Laser Pulpotomy.

In the past, Early childhood caries was attributed to the fact that babies were sucking on their formula milk bottle in bed and going to sleep with it, thus creating an environment for the decay-causing bacteria to thrive on the pooled and fermenting milk on the surface of their teeth.

This has changed today and there seem to be other aggravating factors. Thorough attention has to be given by parents to keep the teeth clean from the bacteria that cause this condition.

Diet, as well as proper oral hygiene, Xylitol gels, possibly combined with some homeopathic remedies, as well as proactive dentistry can all be used to prevent or slow down this condition.

Facts about Early Childhood Caries:

1. ECC develops as a result of very early colonization of the baby’s mouth with streptococcus mutans bacteria.
2. The bacterial colonies covering the teeth, known as plaque, will process sugars coming into contact with them and produce acid as a by-product, which in turn will cause enamel to become softer and porous. These white chalky lesions will then progress into the more advanced decay seen in rotting teeth, especially in upper incisors of children between the ages of 2 and 4.

Recent research has shown that neither breastfeeding nor its duration are associated with the risk for early childhood caries. On the other hand, increased risk of ECC is often independently observed in associations with  poverty, and maternal prenatal smoking. Furthermore, some ethnic groups were independently associated with severe early childhood caries.

Reasons for tooth grinding in children are not so much stress related, rather than manifestations of a deficiency in oxygen during sleep. It has been determined that a child who experiences mild to moderate sleep apnea at night will tend to grind, due to the brain sending alarm impulses to the jaw muscles. Sleep apnea in children may be due to enlarged adenoids and tonsils, a lower jaw that has stayed behind in its development, crowded teeth or small arches, a mouth-breathing child with chronic congestion, or other anatomic anomalies.

The good news is that, this condition can almost always be remedied if the proper action is taken early enough.