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Pediatric Patients: Questions and Controversies Interview with Dr. Marvin H. Berman 

Jill Rethman, RDH, BA

They may be small and cute, but they often strike fear in the hearts of many dental professionals. Sometimes they behave like little angels, while other times they can be your worst nightmare! What are some helpful hints for treating pediatric patients? Dr. Marvin Berman is a pediatric dentist who speaks and writes extensively on this topic. Here, he shares his "little" tips with us.

How early is too early for a first dental visit, and how late is too late?

Dr. Berman: It's never too early! In fact, I would like to see pregnant women in the office for an educational visit. That way, I could stress the importance of proper nutrition to ensure the health of the baby. I could even discuss the link between low birth-weight babies and the periodontal health of the mother, along with other issues. I find that moms-to-be have lots of important concerns, and I could address them before the child is born. A child should be seen no later than age two. This is a nice age psychologically and practically. If there are signs of caries or developing malocclusion, they can be detected early and preventive measures can be instituted. Waiting for the school checkup at age five or six is too late, especially for children who are caries-susceptible.

Which is better - bottle - or breast-feeding? When should children stop and how?

Dr. Berman: All indications are that breast-feeding is best. A mother's milk provides important nutrients and disease-fighting substances. Along with the health benefits, there are psychological benefits as well. The bonding process between mother and child that occurs with nursing is a significant event. Don't overindulge the child with either bottle- or breast-feeding. As soon as the child can drink from a "sippy" cup, begin to wean him or her from the bottle or the breast. Remember the parents determine the timing - not the child. Parents should not allow the child to carry the "sippy" cup around, since this can lead to caries and early childhood caries can be devastating.

Who needs pacifiers the most - the kids or the parents? Do they cause harm?

Dr. Berman: The pacifier habit usually starts in the hospital. Nurses try to calm fussy babies by using the pacifiers; this may start a pattern that can become excessive. Overuse can lead to oral problems, such as mouth-breathing, narrowing of the arch, and overcrowding of teeth. As with bottle-weaning, the "cold turkey" approach seems to be the most effective in eliminating a pacifier. Parents need to understand that there will be a period of crying and adjustment, but it works!

What's the best way to stop the thumb-sucking habit?

Dr. Berman: This can be one of the most difficult habits for a child to break. The thumb is attached to the body, so it can't be thrown away like an old security blanket! In my experience, one should never use a punitive approach. If the child is of an age where he can understand that putting of immediate gratification can lead to eventual pleasure, he's ready to be weaned from thumb-sucking. Promising a reward if the child stops sucking his thumb may help; some children can understand this logic even at two or three years old. I sometimes apply a Band-Aid to the thumb, and then give them my card and ask that they call me the next day. If the Band-Aid hasn't come off, that means the child hasn't sucked his thumb and he can return to my office for a special prize. This technique is more effective if instituted by a stranger - like a dentist or hygienist - rather than the parent. If the child is approaching five years of age and is still thumb-sucking, an appliance may be needed to break the habit. At age five, the bone and the permanent teeth can be noticeably affected by thumb-sucking.

Should parents be in the operatory during treatment?

Dr. Berman: I believe parents and children should be separated during treatment. I do, however, make an exception for infants and their mothers, although I do put the baby on my lap during the exam to ease the separation. I call this a "parentectomy." The fact is that children are much better behaved when the parents are not present. Parents bring their own insecurities into the operatory without realizing it. Although they mean well, their anxiety is expressed in phrases like, "Don't worry", or "It won't hurt." The clinician needs to establish trust with parents so they understand that the goal is to provide the best treatment for the child…and the best way is for them to not be present.

What about sedation and general anesthesia? Is this "trip" necessary?

Dr. Berman: There are definitely situations when these techniques are necessary. It should not, however, be the first choice in treating an unruly child - sedation should be a last resort. It's impossible to establish a relationship with a patient when he or she is sedated. An important aspect of being an oral health professional is education, and this is not effective if the patient is sedated. It's interesting to note that when pediatric dentists are surveyed regarding their use of sedation, they respond that they rely on it less as they become more experienced and confident. We should strive to feel such confidence, early on, to minimize the need for drugs.

When and why should we take radiographs of children?

Dr. Berman: There are two times in a child's life when x-rays are mandatory. At age five or six, the primary teeth are exfoliating and the permanent teeth are erupting. A panorex, two periapicals, and two bitewings are definitely needed at this time. These provide baseline information about eruption patterns and other oral conditions. I begin with the anterior periapical radiographs to allow the child to become accustomed to the film in the mouth, thus, making the bitewing procedure easier. X-rays are needed again at age ten to 11. During this time, the last few primary teeth are exfoliating, and an orthodontic referral may be necessary. If trauma occurs, a tooth is loose or discolored, or an abscess is present, an x-ray may be necessary. If the child is caries-susceptible, radiographs are needed more often. Most important, tailor the frequency to the need to the patient.

What are your recommended checkup intervals? Three months? Four months? Six months? When the insurance pays for it?

Dr. Berman: As with the previous discussion on radiographs, checkup intervals should be geared to the need of the patient. Some patients need to be seen more than every six months, especially if a situation is being carefully monitored. What complicates this issue is insurance coverage. I disregard the insurance coverage, and if I have to perform the examination for free, I'll do it for the benefit of the patient. I also attempt to place some guilt on the parents. If the child's health is at risk, the parents should behave responsibly, regardless of insurance coverage.

How about polishing children's teeth? Are we abrading the protective surface of the teeth, or are we removing harmful plaque?

Dr. Berman: While some clinicians advocate selective polishing, in my practice we polish the teeth at each visit. I've found that many times, children have tremendous amounts of plaque and even various types of stains. Furthermore, the polishing procedure accustoms the child to the use of an instrument in his or her mouth. I use polishing as part of the education process by explaining not only what I'm doing, but also why and how the child can keep his or her teeth clean at home. It's another education opportunity.

Why perform fluoride treatments? It's in the water, toothpaste, mouthrinses, and even juices and other beverages. Are we applying too much fluoride?

Dr. Berman: If there is fluoride in the drinking water, additional systemic sources - such as drops or vitamins - are not needed. If fluoride is absent from the water supply, however, it is advisable to provide fluoride supplements from infancy. Fluoride has been proven to be the single most effective way to prevent and reduce decay. If decay does occur, it is less severe and takes place at a much later age. Topical fluorides - such as toothpastes, mouthrinses, and I-office treatments - act synergistically with the fluorides taken systemically, so they are still necessary. I don't advocate a fluoride mouthrinse until the child is old enough to rinse properly. On the other hand, I've found fluoride mouthrinses to be essential or kids in orthodontic treatment. Once again, we must tailor treatment to the specific needs of the patient.

Why "save" baby teeth? Don't they fall out anyway?

Dr. Berman: The most important reason to "save" the primary teeth is to maintain space for the permanent ones. The more posterior the primary tooth, the more important it is to maintain that space. The second primary molar is essential when we look at how the permanent will erupt. Parents need to understand this concept in order to appreciate the need for a space maintainer if a primary tooth is lost prematurely. Once that space is lost and shifting occurs, the child is automatically destined for orthodontic problems. Other considerations, such as proper eating, self-esteem, and comfort are also important when maintaining the primary teeth.

Are stainless steel crowns a conservative or overly aggressive treatment when restoring carious teeth?

Dr. Berman: Some clinicians still feel that amalgams and composites are conservative treatment options for children and the use of stainless steel crown is too aggressive. In many cases, the opposite is true. In my opinion, if a tooth- deciduous or permanent- has enough decay to warrant a crown, then a crown should be placed. It takes half the amount of drilling for a stainless steel crown than for a large restoration. Therefore, it's really the most conservative option in these situations. Furthermore, if the tooth must be present for several years, the stainless steel crown can ensure its viability over the long haul.

What about sealants? Are they underused or overused?

Dr. Berman: I am a firm believer that if a young child has a healthy mouth, with limited risk factors for decay, sealants are not necessary. Remember, once a sealant is placed, the clinician has a responsibility to ensure that the sealant remains intact forever. If a sealant is chipped or washed out, that tooth may be compromised and caries-susceptible. In certain cases, however, sealants can be quite effective. Those patients who are caries-susceptible can greatly benefit from their use. If the sealant is placed, the clinician must inform the parent that the sealant only protects the occlusal surface - not the entire tooth! Many parents believe that once a sealant is placed, the tooth is immune to decay on any surface. Should caries be detected, I recommend crediting the cost of the sealant, and applying that to the cost of the restoration. It makes good sense from a business and personal relationship standpoint.

Is amalgam or composite the best material to restore teeth in children?

Dr. Berman: Unless aesthetics is an issue, I like amalgam. In many situations, it's durable, reliable, and cost-effective. In my opinion, the concern about mercury in amalgams is not scientifically sound. Mercury is released and consumed when we eat a tuna sandwich or shrimp- and probably much more than is released from amalgam restorations. Therefore, I use amalgam routinely with my pediatric patients. By the same token, composite materials are improving, and I am gaining more confidence in them. When the caries is less invasive - composites are ideal.

If they come together, in what sequence should we see family members - the younger or older child first?

Dr. Berman: A three-year-old child has a shorter attention span than a six-year-old. He hasn't had as many experiences in a dental office, or in life, and is more likely to listen! He doesn't know what to expect, so it's up to the clinician to make that initial experience positive. If the younger reacts negatively, you can always say, "He's just a little guy." If you choose to see the big brother first, hoping he will be a good role model, and things don't go well, you have no credibility with the younger child. I always see the younger child first. Then, if the older child misbehaves after the younger one was so good, he feels foolish.

Is it possible to stop children from eating candy and sweet snacks? How can we use proper nutrition to reduce caries?

Dr. Berman: Kids will not stop eating candy or sweets, and it's not necessary to stop them. The most critical issue is the snaking between meals. It is impossible to brush each time, so snacks should be limited in number and consist only of nonfermentable carbohydrates. To stop a child from snacking is unrealistic, however, by controlling their intake, susceptibility can be reduced. If a child has access to snacks throughout the day - including bottles, juices, dry cereals, and so on - he or she won't want to eat a healthy dinner. Furthermore, his or her teeth have been bathed in carbohydrates all day. If the child is caries-susceptible, this can create disaster!

Should kids brush by themselves? Should they use a manual or powered toothbrush? How much toothpaste should they use? Which one?

Dr. Berman: For safety and effectiveness, parents should brush a toddler's teeth. As the toddler gets older, parents should still actively participate. It's important for parents to make sure the child doesn't swallow the toothpaste, and before age five or six this can be a problem. If good techniques are used, powered brushes can be more effective then manual ones. In addition, the novelty of using a powered brush might encourage good oral hygiene habits. The downside of a powered brush is that children tend to leave the brush in one area of the mouth. A manual brush designed for children helps develop dexterity. The handle is important - it needs to be on that allows a child to control the brush - a thicker grip is always good. As far as toothpastes are concerned, use as little as possible on the brush. As we all know, it the act of brushing, not the paste, that removes plaque. The best toothpaste for kids is on that contains fluoride, has a neutral flavor, and is approved by the ADA. Avoid strong tastes like wintergreen or mint - it turns kids off immediately!

Thank you, Dr. Berman, for your insight and advice!

Jill Rethman, RDH, BA, "Pediatric Patients: Questions and Controversies Interview with Dr. Marvin H. Berman," The Journal of Pediatric Hygiene, January/February 2002, pp. 19-22.