Dr. Karen Benitez

Dr. Benitez answers, ‘Why save a baby tooth with a pulpotomy or an indirect pulp cap’?

April 15, 2019

Dr. Karen Benitez, founder & designer, board certified pediatric dentist at Chevy Chase Pediatric Dentistry writes a series of guest posts related to adolescent dentistry and questions for Beltway Bambinos based on questions and concerns she frequently receives from patients. If you have a topic you’d like to see her feature, leave it in the comments. Below is a list of previous topics Dr. Benitez has covered; an invaluable source of information for all parents.

I touched on the subject of cavities early on in my blog posts for Beltway Bambinos. The idea was to lightly introduce the various treatment approaches available to manage or treat cavities. In this post I speak on two very common procedures in pediatric dentistry, and in my opinion, very important procedures to be able to perform on a baby tooth: a pulpotomy or an indirect pulp cap. I hope this is insightful in your preparation for your child’s upcoming treatment.

Generally speaking, teeth that would potentially need these treatment options are affected with large cavities—more specifically, cavities encroaching on the neurovascular central mass of soft tissue, simply referred to as the nerve. It is the size of the cavity and the proximity to the nerve that warrants the question by all dentists of (1) vitality of the tooth– is it living? and (2) restorablilty–is there enough remaining sound tooth structure to build on?

At your exam visit, your dentist will share with you their need for x-rays to determine the depth of decay and if there is evidence of infection with the tooth in question. Sometimes, there is not yet evident infection, but there is too much tooth structure lost and no ability to restore the tooth. An extraction is warranted in either the situation of an infection or insufficient tooth structure remaining. Both a pulpotomy and an indirect pulp cap are procedures designated for teeth that are still considered alive (vital), but have decay encroaching upon or invading the nerve.

But why perform these procedures on teeth with large or deep decay? The truth is, that maintaining the baby tooth is hugely important for preserving space for the permanent tooth to follow. Baby teeth help the arches to grow in preparation for ideal facial development and speech. It is not a preferred practice to have to remove any number of baby teeth (unless otherwise better for skeletal growth accommodation). The procedure of a baby pulpotomy is mostly practiced on baby molars.

A pulpotomy is commonly referred to as a “baby root canal” because it is a cleaning out of the nerve tissue of the baby tooth. Unlike a permanent tooth, the baby teeth are only treated in the top part of the nerve within the crown. We leave behind the nerve tissue in the root lengths to allow for natural resorption during the transition of baby teeth to permanent teeth. A medicated putty is placed in the crevice that the coronal nerve occupied, followed by a full-coverage stainless steel crown or white-zirconia crown (if eligible). In cleaning out the infected coronal nerve tissue, you are preserving the remainder of the tooth to be able to carry out its job of holding space for the following permanent tooth. Remember there are circumstances of no permanent tooth, hence all the more reason to maintain the baby tooth!

An indirect pulp cap is practiced for cavities very close to the nerve, but not quite in it. It is not uncommon to leave a tiny amount of decay at the most inner, proximal part closest to the nerve entry. You place a fluoride-releasing glass ionomer material to protect that remaining bacterial cavity from growing into the nerve. Then a final filling of full-coverage stainless steel crown (1) or white-zirconia crown (2) is placed over the tooth.

Both a pulpotomy or indirect pulp cap are optimal ways to preserve the design of baby teeth in preparation for the permanent teeth ahead. It is my first line of restoration for teeth involved with large cavities. Both are vastly considered the standard of care in pediatric dentistry. I hope this is insightful in your preparation for your child’s upcoming treatment.

We at Chevy Chase Pediatric Dentistry welcome your child to come in and have a look. It would be our pleasure to have you! You can also find us as Bethesda Magazine’s Face of Pediatric Dentistry, view our Top Docs video and read our stellar reviews on Yelp, Google and ZocDoc. Follow us on Facebook to learn more about what Chevy Chase Pediatric Dentistry is all about focusing on your kids.

Location: 8401 Connecticut Ave #650 Chevy Chase, MD. 20815

Phone: 301-272-1246

-Dr. Karen Benitez, DDS

It may not always be a walk in the park for your child at the dentist and that’s okay

March 20, 2019

Dr. Karen Benitez, founder & designer, board certified pediatric dentist at Chevy Chase Pediatric Dentistry writes a series of guest posts related to adolescent dentistry and questions for us based on questions and concerns she frequently receives from patients. If you have a topic you’d like to see her feature, leave it in the comments.

The first post was one that many parents wonder about; whether it is necessary for your child to visit a pediatric dentist and how the experience will differ from just taking them to the dentist you see. The second post addresses the topic of why x-rays are important for your child to have. The third post explained why your child may be referred to an orthodontist at what may seem like a young age, followed with an article all about cavities and how to proceed. She has also written the following posts; Food and drink choice; an increased risk of cavities?, Tips on brushing and flossing and fluoride and sealants.

I present this subject because I am a realist on behalf of the parents for whom upon mentioning an upcoming dental visit to their children, are in turn facing endless questions or conversations of self-assurance by their kids. I often hear from parents that their child would not stop pep-talking themselves about how well they were going to do this time and how excited they were to get it all done this time. Sometimes, these kids come to the office and halt in the doorway, no longer so sure of their ability to comply. Again, this is OK! [Read more…]

Let’s talk fluoride and sealants with Dr. Karen Benitez

February 12, 2019

The first post was one that many parents wonder about; whether it is necessary for your child to visit a pediatric dentist and how the experience will differ from just taking them to the dentist you see. The second post addresses the topic of why x-rays are important for your child to have. The third post explained why your child may be referred to an orthodontist at what may seem like a young age, followed with an article all about cavities and how to proceed. The last two posts were Food and drink choice; an increased risk of cavities? and Tips on brushing and flossing.

Most of us have heard of these two things when going to the dentist. It is rather familiar territory, but let’s talk about why we provide them or discuss their home use (fluoridated toothpaste). These two discussion points are considered part of a cavity-reducing regimen. [Read more…]

When should I schedule my child’s first dental visit?

October 16, 2018

Dr. Karen Benitez, founder & designer, board certified pediatric dentist at Chevy Chase Pediatric Dentistry is writing a series of guest posts related to adolescent dentistry and questions she frequently receives from patients that may be of interest to you. If you have a topic you’d like to see her feature, leave it in the comments.

The first post was one that many parents wonder about; whether it is necessary for your child to visit a pediatric dentist and how the experience will differ from just taking them to the dentist you see. The second post addresses the topic of why x-rays are important for your child to have. The third post explained why your child may be referred to an orthodontist at what may seem like a young age, followed with an article all about cavities and how to proceed.The last two posts were Food and drink choice; an increased risk of cavities? and Tips on brushing and flossing.

A common question that I am asked is “When should I schedule my child’s first dental visit?”. It’s a great question and I am so happy to discuss the importance of having your child see a pediatric dentist before they turn one. The American Academy of Pediatric Dentistry (AAPD), has been lobbying and advocating for the American Academy of Pediatrics(AAP) to recommend for an infant’s first dental check-up visit by their first birthday. By 2002-03, the AAP advised finding establishing an oral health risk assessment by 6 months age and establishing a dental home by 12 months age. Why would this be so important to a community of dentists dedicated to oral health of young children? I will be frank and say that if following previous guidelines and waiting until later, more cooperative ages of 2-½ or 3 years age, it is often too late for prevention!

In our first meeting I mention two key elements surrounding oral health that the AAP and AAPD address: oral health risk assessment and a dental home. An oral health risk assessment includes the following factors for review during an exam: biological, protective and clinical findings. They are broken up into two categories of risk: high vs low. Furthermore, it is broken up into age groups. This assessment requires rather extensive examination. Various questions are posed and my assessment of the parents would be involved. The other term, a dental home, is a comprehensive, continuously accessible, family-centered established relationship with a dental provider. In other words, having and maintaining a relationship with your dental provider every 6 months.

When parents think of early check-ups with a dentist, their question is “Can my child have cavities this young?” Let’s begin with the topic of diagnosis. Though studies show that cavities are elevated in differing socioeconomic backgrounds, I am finding decay irregardless of this. Did you know that cavities are considered a common chronic disease in children; meaning that it is continuous, occurring again and again. It is because of the chronic behavior of cavities that I am hugely insistent on regular exams, even more so after extensive dental treatment has been completed. As I had mentioned in an early blog, I look for shadows or prominent food traps. There is likely a pattern lending to a lack of access during brushing and flossing or regular food traps that if inconsistent in brushing and flossing; allowing for the process of a cavity to proceed. Check out the Colgate website indicating early signs of cavities, known as white spot lesions. These are relatively common in many patients and open up conversation about diet and hygiene modifications. When I see these, I generally increase a patient’s exam regimen to every 3 months.

I prefer that we meet early on and I help parents get comfortable in preventive measures as opposed to addressing cavity management. Most parents are very appreciative after our infant exams and feel that they can ask me various questions. Often parents express that after their infant exam they feel more comfortable in their approach, albeit still adjusting to the wiggles and temperament that accompanies this age group. I assure parents that it is ok to at times to feel like it can be frustrating because we all know that even babies and toddlers start to want to take control in this too and battle with us trying to help them. I have 3 little kids– trust me when I say I get it! It can be exhausting for such a simple task, just like changing a diaper or getting them in a car seat but it is definitely important to continue to brush their teeth.

Beyond the obvious question of cavities, is the relationship that we establish at this age. I meet some families of babies in the development of crawling or early steps. We all know how many tumbles they can take and yes, accidents can occur that involve the teeth. It does not always mean that our meeting will lend to treatment needs for injured teeth, but at least an initial meeting by their first birthday has made me somewhat familiar to both parents and baby. I prefer that you call me in the event of an injury so I can advise on how you deal with the injury and perhaps avoid unnecessary trips to the emergency department.

The early months of erupting teeth can lend to behavior changes in your baby. Parents benefit from the assurance of an exam and discussion surrounding their appropriate development and comfort management during the process. During this exam we look at the gum tissue and I guide my families to feel around with the pad of their finger to determine when the next set of teeth will be coming in. This can easily be done following brushing to keep ahead of the potential discomfort. I assess for any pathology of the gums, mostly of no concern, and for any potential eruption cysts with teeth in the process of coming in. There are various non-pharmaceutical options for teething on the market and it’s important to discuss these. I am not in preference of the use of topical anesthetic as this is not localized to the area you target, but rather can cause numbing beyond the area. It’s best to use cool materials or foods like wet washcloth or cool cucumbers or a food pouch and even frozen berries. There are various teething necklaces that can be worn by caretakers and parents. Keep in mind that your teething rings should not contain small pieces. Evaluate for a continuous form that can’t separate as a choking hazard during their use. Apply gentle massaging pressure with the pad of your finger after brushing. Babies still appreciate a good finger from mom or dad to gnaw on! Just as you would not put your baby to sleep with a bib, or a bumper guard, a necklace can pose similar risk with movement, applying pressure to their neck—an airway concern. It’s safest to use the above methods and guidance and the use of Tylenol for comfort.

It’s a great assurance for parents to come in for early check-ups since there can be many questions that arise. We are your guides in establishing good oral and dietary practices early on. This early relationship with your pediatric dentist allows you to consult with one in the time of doubt or need. Furthermore, I encourage you to seek counsel and guidance through the AAPD website. It provides a wealth of information and also allows you to find a pediatric dentist near you.

We at Chevy Chase Pediatric Dentistry welcome your child to come in and have a look. It would be our pleasure to have you!

You can also find us as Bethesda Magazine’s Face of Pediatric Dentistry, view our Top Docs video and read our stellar reviews on Yelp, Google and ZocDoc. Follow us on Facebook to learn more about what Chevy Chase Pediatric Dentistry is all about…Focusing on your kids.

-Dr. Karen Benitez, DDS

Location: 8401 Connecticut Ave #650 Chevy Chase, MD. 20815
Phone: 301-272-1246

Courtesy of photos credited to: ADA (tooth sequence chart); Target (one balloon banner); Pinterest (natural teething cucumbers); Target (frozen food pouches).

Tips on brushing and flossing your child’s teeth

October 2, 2018

Dr. Karen Benitez, founder & designer, board certified pediatric dentist at Chevy Chase Pediatric Dentistry will be writing a series of guest posts related to adolescent dentistry and questions she frequently receives from patients that may be of interest to you. If you have a topic you’d like to see her feature, leave it in the comments.

The first post was one that many parents wonder about; whether it is necessary for your child to visit a pediatric dentist and how the experience will differ from just taking them to the dentist you see. The second post addresses the topic of why x-rays are important for your child to have. The third post explained why your child may be referred to an orthodontist at what may seem like a young age, followed with an article all about cavities and how to proceed.The final post was Food and drink choice; an increased risk of cavities?

When I first meet families in the office, I like to understand their home care routine. I ask parents if they brush and floss for their kids. Most parents are brushing, but it’s hit or miss who already flosses. I would like to really discuss my best advice because I have seen how much it can help kids who are not only developing in their dexterity and comprehension, but are gaining confidence in their dental visits. Considering the last blog of food and drink choices, it seems like a great point on how to protect their pearly whites through hygiene. Simple as it may seem, brushing (and flossing) can be a bit challenging for many families. Let’s break down the discussion by ages: toddlers, school-age kids and teens.

For my toddler screenings (beginning by age 1 year) I begin discussing positioning because I have come across many variations. I use my small teaching dinosaur to demonstrate first what I recommend during this exam. It keeps the tiny toddlers entertained and helps parents understand what I will be doing before the start of the exam. In the years of seeing wriggly teeny toddlers, I have deducted that my best viewpoint is also the one you should position yourself for. When I examine a baby or toddler (this also pertains to kids too scared to sit in the dental chair), I position myself in front of the parent, preparing for a knee-to-knee exam. This position provides for a stable surface created by our thighs in which your child faces you, legs straddling your waistline, and then their head is reclined into my lap. It’s the position dental professionals take for stabilizing your child, but also for best view and access. I encourage parents to appreciate the following from this position: your child is limited in how they can move away from you, this “cave-like” mouth is now facing upward to a focal light from above, the tongue naturally drops back in the mouth allowing for access to the inner side of the lower teeth, and you have a free hand to move the muscle groups of lips and cheeks away from the area you are targeting in brushing. This position also helps for your young child to get familiar with a reclined position, the same in which is done in the office. It may take two people on a bed or a floor at home to brush your child and that’s okay, you will get the hang of it and so will your child. I encourage you to do so if your child is wriggly so you can be quick and efficient by having a partner aid in stabilizing. Make it fun by searching for treasures or superheroes hiding between teeth. Kids enjoy a song too. Just be playful and cheery about it so your kids learn to play along.

Kids appropriately start to develop autonomy as they grow to be school-age. They want to do it all themselves like the “big kids” that they are. There are great benefits in this development. They are learning the dexterity it requires to brush the front teeth, then moving to the back teeth. Watch your own hand movements in the mirror next time to appreciate the motions taken to move to all areas of the mouth. Flossing is even more tricky to learn. Be patient when I ask that you allow your little ones to brush themselves, but then you go in and brush and floss for them after. Young school-aged kids really cannot floss themselves at this point. It’s the trickiest of the tasks to learn. I tell parents that the easiest position for the school-aged kids is also in a reclined position into your lap with their mouth up. Use a sitting position on a chair or the bed or floor again. You gain the same benefits of getting a real up-close view, but can use your free hand to move the lips and cheeks out of the way. Remember that those cute little lips and cheeks are all muscle groups and sometimes you find resistance in access to areas because kids too can use them to push you out. They may not even realize they are doing it. Most of us say, “open wide”, which helps in getting most areas of the mouth, but the cheek side access could benefit from closing a bit, so the cheek muscles are not so tightly pressed against the teeth, leaving little wiggle room for the brushing motion.

I like to engage older kids and teens in understanding why they need to brush and how to best understand access. They are in an age of changing teeth and gaining more and more permanent teeth (what I refer to as your forever-ever teeth). Teens are just as dependent on an adult for guidance in oral hygiene as younger kids, but for different reasons. They are in an age of development and varying hormones. These hormones can cause differing degrees of gingival concerns which are highly hygiene-dependent. Some parents struggle with this age group and their overall hygiene, not only their oral hygiene. Be patient and keep your exams and cleaning regular to aid in building confidence in them when it comes to maintaining their oral and overall health. This is the latter age for my parents to aid in their children’s brushing and flossing. Gentle reminders can help. Disclosing toothpastes or mouthwashes can benefit them in realizing where they are missing. Keep in mind that crowding may also lend to creating difficult-to-reach areas. Use a mirror during the process and self-evaluate after. I call this the shiny versus matted test. Clean teeth reveal the natural sheen of enamel whereas remaining plaque dulls the sheen, appearing matted. Teens in this age group may be in orthodontics. The appliances may make access a bit trickier. I provide guidance on shifting the lower jaw to make room, using a smaller head toothbrush to get in the tighter spacing, brushing technique variations and platapus flossers (which kids really are finding helpful), as well as a needle and thread floss system. As for the varied technique on brushing with braces, try to visualize the line of brackets and focus on brushing directly over the brackets and then at 45-degree angles from above and below the brackets. The goal is to use the sweeping action of the soft bristles to dislodge debris from the appliances and tooth surfaces. If children are able to brush at school, they should do rigorous water swishing to expel as much as they can. It’s important to have your orthodontic team aid in evaluating at each adjustment visit and provide tips on improvements, as needed. Helping your teens understand the importance of maintaining oral health is critical to their overall healthy growth and development. The mouth is the entryway to the rest of the body’s system. It is as important to consider the foods you eat as it is the bacterial load you carry in your mouth when discussing overall health.

I provide handled flossers, which are very common in the pediatric dental community. They make flossing much easier by another person, as well as for kids to hold as they are learning more about practicing their oral hygiene. I assess your child to see if they have spacing between their teeth. If they all come into contact, I call this floss-dependent to encourage just how much I want you to floss. Most of the littles have space between their front teeth, but contacts between the molars. I guide my families in demonstrating the flossing technique as well. Flossing allows us to clean these inner walls that the toothbrush can’t reach. It completes the oral hygiene regimen. My advice is to brush and floss morning and evening, but I hear from parents that the flossing advice is very new to them conceptually on their young child. I encourage to get good at night-time flossing and then to add it to their morning routine. The evening wind-down time for bed is a calmer time than the morning rush to learn an additional step in the routine. Let your older kids see you brushing and flossing as well. It helps for them to learn that this is what all people do to take care of our teeth. Making funny faces is all part of the game of access when brushing!

I also fully encourage the use of fluoridated toothpaste. I will discuss fluoride again in another blog, but for now understanding the amount is important. See the image below, provided by the ADA. My advice to parents is to stick to toothpastes with the ADA seal of approval for validity in what is advertised on the tube. Children younger than 3 years age use a small grain of rice-sized versus a pea-sized amount for kids 3-6 years age.

I demonstrate the amount at my exams based on ages. If parents are reluctant for the use of fluoridated toothpaste, I encourage use for bedtime brushing or alternating evenings. I’ll elaborate more on the benefits and use of fluoridated hygiene options as well as sealants as a blog on cavity prevention.

As your kids get older, their ability to brush and floss does improve. There are products on the market as mouthwashes or toothpastes that stain the plaque—disclosing agents. These products are useful for the kids starting at approximately 7 to 8 years age onward. They use the disclosing agent to visualize the now brightly-colored plaque and target their brushing to remove it all. It’s a great learning tool and motivates kids to learn the reason we brush.

There are various apps and timer games that help for kids to target all teeth by groups for an approximate 2-minute brushing duration. You can’t go wrong with these! Many parents will start using a battery-operated or electric toothbrush. I only suggest you look at the size of the toothbrush head to make sure it is small enough to be useful and that not too much pressure be exerted on the teeth. I still support the use of traditional, soft manual toothbrush as what is gifted at your cleaning and exam visit.

It is critical to fully engage with your dentist and hygienist during your regular 6-month exam and cleaning. Each age group is unique in needs and development of the skill of oral hygiene. Having parental involvement during my exams is critical in gaining confidence in the process.

We at Chevy Chase Pediatric Dentistry welcome your child to come in and have a look. It would be our pleasure to have you!

-Dr. Karen Benitez, DDS

Location: 8401 Connecticut Ave #650 Chevy Chase, MD. 20815
Phone: 301-272-1246

Food and drink choice; an increased risk of cavities?

September 18, 2018

The first post was one that many parents wonder about; whether it is necessary for your child to visit a pediatric dentist and how the experience will differ from just taking them to the dentist you see. The second post addresses the topic of why x-rays are important for your child to have. The third post explained why your child may be referred to an orthodontist at what may seem like a young age. The last post was all about cavities and how to proceed.

This blog subject is to address food choices and how they relate to an increased risk of cavities (not to mention overall body health). Let me first make a disclaimer that I am not a sugar-free, carbohydrate-free mommy of three. I too juggle rushing out the door and what will we all have for dinner as we dart in and out of after school engagements. Our weekends can be rather hectic and some food groups might be repeated more than I care to admit but we don’t make a habit of it.

In my daily dialogue with parents about what their kids are eating and drinking, I chime in that there is no perfect recipe to be cavity-free, but there are habits that we can fall into that can increase the risks. I feel that life is incredibly hectic for all of us and it seems exceptionally frustrating to go to the dentist and hear your little one has cavities. I see the frustration in parents’ eyes and the feeling of letting their kids down. I don’t keep a “cavity-free” club because kids themselves feel upset to hear they have a cavity. I am here as your liaison to help you better understand the process and an advisor on what changes to make. I ask for routine exams because if missed every 6 months, it’s super easy for cavities to get growing!

So why has the subject of food and drinks made it to this blog? Well, we are faced with a plethora of options, frankly. It’s not such a simple answer any more of what your kids will drink and it varies by age groups. Just to give a visual, walk into any grocery store, convenient store or gas station and you will be welcomed by an abundance of options of beverages and convenient snacks. This is what our market places now look like because we really are a society on-the-go. Drive (or walk) down any city street and you can’t go far without bumping into a Starbucks Frappuccino advertisement or a treat offering. Snacks now come in convenient pouches or bags because the consumers really are constantly in movement. So I bring to your attention, the hidden sugar intake in some of these—not to call out any brands, but to bring awareness to the subject.

Let’s begin to understand the steps of the development of cavities. The cavity process requires these parts: a bacteria source, a sugar source, a susceptible tooth, and time. We all carry a very specific bacteria involved in the cavity development: streptococcus mutans. This little bugger initiates the cavity process by being fed sugar from what we eat, creating an acid. Cavities are an active process of lower pH levels (more acidic saliva). It is the acidity level that allows for the tooth structure to become demineralized (eaten away), hence a susceptible tooth. This combination of bacteria-laden plaque, sitting proximal to our teeth, in a sugary, acidic salivary flow, is only awaiting time to actually cause the demineralized cavity.

We are all learning so much more about the breakdown of our carbohydrates into sugars. We know the more whole grain, the less the sugar. Every time we eat, the food choices we make affect the pH levels of our saliva. Our children in particular snack more often than we do and carry sippy cups in early years. The frequency of snacking easily lowers the salivary pH, maintaining a risky environment of sugary acidic attacks on these tiny pearly teeth.

This is a great subject matter itself: drinks! I find this to be the sneakiest of culprits to lowering the pH. I ask that parents be aware of the amount of sugar on labels for foods and drinks. It’s the easiest way for kids to ingest tons of sugar without our realizing it. Sports drinks, juices, any flavored milk—all these are to be checked for increases in sugar. The container in which they come in is far greater a serving size than the kids should take in, but they do. My favorite advice for parents is to drink WATER! If that’s not always cutting it, dilute the sports drink or juice and keep them to a limited intake. Milk naturally has sugar, no matter what milk you ingest. Keep it white—no additional flavors to sweeten it. The sweet taste that our kids are getting is altering their palate. No longer will low-sugar berries and foods appeal to them because they are acutely aware of how much less of “flavor” they offer compared to the sweet stuff. Conveniently packaged pouches of yogurt are also in my category of sweetened milk. Sure, they taste great and are easy to pack, but they also contain far more sugar than we should have them consume. Look for low-sugar options per serving size as consumers!

Every age group has its vice or lifestyle that might lend to higher sugar intake. I find that most parents are already acutely aware of the toddler-age advice of limited juice intake. Thankfully most of my parents are also in the habit of using sippy cups, no-drip rimmed cups or straw cups sooner with only water while on-the-go. This is exceptionally helpful in the young years of trying to maintain healthy hydration and dietary habits. I do find that as our kids get older and into sports, or the teenage coffee shop social, we increase risks of liquid sugar intake in very critical years. These are the years of braces and varying stages of the developing permanent teeth—or as I call them—your “forever-ever teeth”! I want parents to be aware of the drink options their kids are commonly exposed to, be it sports drinks, sodas, coffee drinks because of the frequency of acid attacks the sugar intake is causing.

Being acutely aware of the grams of sugar in the foods our kids (and ourselves) take in daily can actually be frightening! I think we all could benefit from minding this and reserving additional sugars in treats. Ice cream and cakes as treats adhere less to the nooks and crannies of teeth than candies. It’s the same example of Oreos and Cheetos I use below—anything that sticks to the teeth, allows more access of time to a susceptible tooth. Thankfully there are food products on the market aware of the excess sugars, offering low-sugar options. They provide tasty snacks with less sugar and more healthy fillers. It might take time to adjust to some of these snacks, but it’s worth it. I tend to stray from food packaging designed for kids. At least always compare the sugar to see if it’s a good decision.

It’s no surprise kids come into the office for a cleaning having eaten a snack. This is actually a great teaching moment for me as food remains in the grooves and in between walls of teeth. I engage parents to peer over my shoulder as I demonstrate how to brush and floss. It really takes good focus for some foods to be properly removed from these grooves and in-between walls. The perfect examples of the tenacity of some foods are Cheetos and Oreos! Seriously, they are incredibly difficult to remove even after bouts of brushing, flossing and rigorous swishing and spitting. Look at the images below to see how these foods stick into the grooves. Their bright and dark colors allow you to see them clearly, but other foods aren’t so easy to see. It provides a great visual on the behavior of food retention on the teeth that over time can cause cavities if not properly brushed and flossed. Say “cheese”!

Speaking of “cheese”, did you know that eating cheese helps to decrease cavity risks? Cheese is shown to elevate salivary pH making it more basic. That’s the opposite of what most food choices containing sugar do (they make your saliva more acidic). I love the idea of kids snacking on cheese and yes, there are conveniently packaged options out there. I could have been French with my love of cheese and I try to pass that along to my kiddos!

Another great idea that you will hear me say is WATER, WATER, WATER! Nothing hydrates the body better. I tell my little patients that water feeds their bodies. I ask them if they think we would feed our little gardens of flowers and vegetables juice or water to grow. They crinkle their noses and look at me like I’m absolutely nutty! I tell them that their bodies are also growing, and like their garden flowers and veggies, WATER is their best choice. Kids are so smart. “The solution to pollution is dilution”, that’s what my oral surgery attending would always say and I agree. Let’s dilute any sugar accumulation with water. I prefer they rinse and spit, otherwise it’s just all going down the drain to their bellies.

Thanks for tuning in again! Keep posted for the following subject: Oral Hygiene, Ah! I will discuss other tips I find exceptionally helpful, including early assessments! It’s clear that we all eat, but are we all setting up our kids with excellent brushing and flossing to lessen the cavity risks?

We at Chevy Chase Pediatric Dentistry welcome your child to come in and have a look. It would be our pleasure to have you!

You can also find us as Bethesda Magazine’s Face of Pediatric Dentistry, view our Top Docs video and read our stellar reviews on Yelp, GoogleandZocDoc. Follow us on Facebook to learn more about what Chevy Chase Pediatric Dentistry is all about…Focusing on your kids.

-Dr. Karen Benitez, DDS

Location: 8401 Connecticut Ave #650 Chevy Chase, MD. 20815
Phone: 301-272-1246

My child has cavities, now what?

August 22, 2018

Upon learning that your child has cavities, most parents want to learn what the next steps would be towards treatment. The variety of treatment approaches is a complex subject matter because it varies vastly per patient and situation, as well as within a family. These options are specific to each child and as we all know, our kids can be different.

As a general rule, I prefer not discussing cavities in the presence of your young or nervous child. Some kids are upset by the news of cavities and to alleviate this, we maintain a distance in the conversation and phrase their upcoming visit in very friendly terms.

I begin by outlining possible treatment approaches. Some common options include: deferred treatment (with or without fluoride varnish or silver diamine fluoride), treatment with or without nitrous oxide (laughing gas), mild sedation or general anesthesia.

The first step is determining if we should take an active role in treating these cavities in the current time or monitor them. Monitoring of cavities is often used if the cavities are smaller in size. Starter cavities are called incipient cavities. Depending on the number of incipient cavities seen, I may have your child be seen every 3 months to monitor.

If the cavity grows in size but perhaps your child is not yet ready for the steps involved in restoring the teeth, another option is proposed. In select situations such as these, where the rate of growth of cavities can be controlled, I propose deferred treatment. This option does not suggest that we are never going to restore the cavities, but that we are tracking your child’s development, as well as cavity growth, to determine a better time in the near future to approach treatment. I schedule your child for limited exams every 3 months until a more definitive plan is made.

Deferred treatment can involve the use of materials proven to slow down the growth rate of the cavity-causing bacteria. These materials include fluoride varnish or silver diamine fluoride (SDF). The latest option of silver diamine fluoride (SDF) is of increased discussion and use with larger cavities in a child not yet ready to undergo dental treatment, because it is proven to be more effective than fluoride varnish. It is a clear, liquid material, similar to the bonding agent used for white fillings, that helps to stop the growth of the cavity. One caveat in the use of this material is that it turns the lesion black and yes, it is noticeable, but effective for its intended use! It is generally followed with the application of fluoride varnish. The use of SDF is often used to gain time for the child to develop to better tolerate treatment at a later time.

For kids who are on path to receive dental treatment my first line of treatment is to determine whether nitrous oxide (laughing gas) would be used or not. Some kids are fully prepared for no agent to be used to modify their tolerance of treatment. These kids bypass the use of nitrous oxide, whereas others would benefit from additional support—introducing nitrous oxide.

So what is nitrous and why is it used? Nitrous oxide is a common inhaled gas used in dentistry because of its ease of use and tolerance by the vast population. It’s an air that is breathed through a nose piece connected to the source of the mixed agents of nitrous oxide and oxygen. It is used as a mild to moderate sedative because of its potential to be titrated (increased or decreased for effect), with caution. It is proven to have both analgesic (numbing) and anxiolytic (anxiety-reducing) properties, so it works great in cases with moderate treatment needs. In some cases, the analgesic component is sufficient enough to not use local anesthetic, however, be aware that we are talking limited situations of small cavities. Nitrous oxide is not metabolized by the body, so at the end of treatment 100% oxygen is breathed in, as the effects of the nitrous oxide are being eliminated. Unlike medicines, nitrous does not go through the digestive system, being excreted in hours to come. It is the easiest, least invasive option in helping kids tolerate some uncomfortable procedures.

If your child is neither a candidate for treatment with or without nitrous, and would benefit from additional support for their dental treatment, a step up in my “tool box” is a mild sedation. I offer this option when I find that your child is a good candidate for it. Not all children can be given an oral sedative, based on their age, medical history and cavity presentation. The goal of a mild sedation is to protect the child’s mental awareness of the treatment and most certainly to maintain a safe measure for treatment. The options vary per dentist, but this option utilizes a weight-based dosage of sedative medications targeted for a MILD response. A mild sedation functions by suppressing the central nervous system, allowing relief of anxiety to your child, providing a timely treatment option. Some children are exceptionally nervous for treatment and without using further agents to make them more calm and comfortable, even treatment with nitrous is not accepted by them. I have had children who will not even sit in the dental chair but have cavities beyond the size of monitoring or deferring treatment. Having the option of an oral sedative has truly helped these children, and their parents, who are not ready for the most advanced option of general anesthesia. Your child IS NOT ASLEEP with an oral sedative. In fact, I am very clear, that the dosage is provided to suffice a mild effect. The goal is for your child and I to remain in conversation about what is happening and to alter their perception of what they imagine is going to happen. I often find that my patients who have had favorable dental experiences in this manner really do better tolerate dental treatment in the future with less apprehensions. Their confidence is elevated in their successful treatment!

Keep in mind that the more advanced routes now being discussed do carry increases in risks. When medications are administered, the risks involve respiratory (breathing) and cardiac (heart) function. A sedation uses nitrous oxide, in most cases, as well as monitoring of your child’s heart rate and breathing via a pulse oximeter with capacity to include carbon dioxide monitoring and a precordial stethoscope. All medications used have a reversal agent and all calculations are prepared beforehand. Safety margins are maintained through the appropriate selection of medications, adherence to dose recommendations, as well as the assessment of qualifying patients. As a Pediatric Dentist, we receive training in mild sedation as an alternative for your child to tolerate treatment. In order to provide mild sedation as a service in my office, both myself as a practitioner and my office are licensed by the Maryland State Board through an oral exam and site assessment. Again, not all children are candidates for this option, or perhaps still require a more advanced method to tolerate their dental needs, hence another option is available.

For children who are unable to receive dental treatment in the most straightforward of manners (with or without nitrous oxide), nor a candidate for a mild sedation, there exists the option of general anesthesia. This is a treatment option in which your child is fully asleep and is routinely performed in a hospital or surgical center by an anesthesiologist. It is the greatest depth of sedation that can be provided and is my last alternative in most cases, with various exceptions. This treatment approach is generally considered the most advanced due to the depth of suppression of the central nervous system. Only qualified doctors or nurse anesthetists provide this medical care. It is an environment in which very limited persons are allowed. Only the anesthesiologist, the dentist, the dental assistant and the surgical nurse are in the operating suite, working together to ensure a safe and prompt procedure for your child. In the case of general anesthesia, our practice philosophy is generally to provide any and all treatment needs to avoid further dental needs in the dental office setting. In other words, some providers are more in line with treating even smaller cavities that would grow over time.

Neither a mild sedation nor hospital dentistry are a provider’s first choice of treatment, however, given the significant rise in cavities seen in younger and younger patients, we all have experienced an increasing need in such options for children to be able to restore their teeth.

Many in the general population ask, “But they are just baby teeth, won’t they all fall out?”. It is true that most baby teeth are shed to be replaced by a permanent tooth, but this occurs over the course of approximately 6 years, beginning around 6-7 years age. Not all permanent teeth formulate, hence maintenance of the baby tooth is more critical to the child, and the number of cavities seen does increase the risk of baby teeth becoming infected, causing pain and early loss. Younger children are seen with cavities as well. I really wish to change the thought that baby teeth are not so important because they really are and keeping your child cavity-free or minimal cavities, is my primary goal. These options discussed are for managing already existing cavities, or other dental needs, that if left untreated, can cause pain and infection for your child.

It is my hope that this helps you to understand steps involved in the decision-making process of how to provide dental treatment for your young ones. Furthermore, I hope that this helps to realize the importance of regular check-ups and establishing a relationship with a dental provider that you can really learn from and grow together in best interest for your child. These early habits of prevention are learned just as much as other hygiene and dietary practices are. Help us grow strong, healthy kids, with smiles designed to last a lifetime!

We at Chevy Chase Pediatric Dentistry welcome your child to come in and have a look. It would be our pleasure to have you!

-Dr. Karen Benitez, DDS

Location: 8401 Connecticut Ave #650 Chevy Chase, MD. 20815
Phone: 301-272-1246

Why an Orthodontic referral for my seven-year-old?

August 1, 2018

Keeping in line with Why do my kids need x-rays? post, it seems only fitting to introduce the subject of an orthodontist. Most kids approximately 7-8 years old will be advised to have a radiograph taken: the panoramic image. This is the image I mentioned in the last blog; used to determine the development and angulations/eruption paths of the permanent teeth. It is a key tool in a pediatric dentist’s treatment plan consideration to determine dental age, cavity treatment options and whether your child is advanced or delayed in the exfoliation process.

The panoramic image is also a key radiographic tool for both the pediatric dentist and orthodontist to collaborate and devise a treatment plan for your child to maximize growth and development potentials. I know what you are thinking—”It seems rather young for my 7-year old to be looking into braces, doesn’t it”? Well, let’s clarify that this referral is not met with all children in this age group beginning in braces following this referral. Collaboration with orthodontic colleagues helps to make sure a critical growth period is not missed in aiding for best overall arch and skeletal tooth orientations.

The age group of 7-10 is one of significant changes. Children will have teeth in transition. Some very obviously loose baby teeth with varying eruption levels of the permanent teeth. Pronounced, serrated edges of the newly erupted, less pristinely white, permanent teeth and non-scalloped gum lines, rather rounded and bulbous, call attention to many parents in a worrisome manner. This is the typical appearance for your young child newly entering what we call the early transitional dentition stage. Some parents note that there is a gap between their top and bottom arches where it appears that one jaw is significantly shorter than the other. A cross-bite may become more evident, be it a full side or a single, front tooth. For all of these visible growth and skeletal variations that may be more evident to a parent now, I provide a friendly reminder that this is truly normal and is the age of orthodontic evaluation precisely to address such variances.

This age group of referral to see the orthodontist generally is in consideration of jaw growth patterns, compromised angulations of permanent teeth as seen on the panoramic image, any habits that may be potentiating a jaw discrepancy, tonsillar/adenoid and tongue posture concerns that may be affecting the arch structures and breathing/snoring intertwined. Most children are prescribed the use of a functional appliance or limited braces. Treatment time is of a shorter duration and maintains an annual assessment into later years to evaluate for comprehensive braces, if needed. The practice of early orthodontic correction also includes the hope to decrease treatment time in the future, if needed.

There also exists a practice of myofunctional therapies, where exercises are used to activate muscles groups (yes, all the cute cheeks, lips and chin are muscles groups!) to correct a soft tissue imbalance to allow more fluid, passive growth potentials of the arches and tongue posturing that might have been stunted by their additional force or compression.

The discussion of all the varying options would be endless. I have selected a few commonly seen images below. These are of the more pronounced clinical observations I would certainly refer for. The appropriate treatment options are not shown, as this is respectfully not my specialty. The determination of treatment options is more complex of a selection process than this forum could erroneously reflect. I leave that discussion up to my orthodontic colleagues. This blog subject calls attention to the reasoning for an early referral and only to show select images of what a parent would recognize as a situation needing treatment.

The first image is that of an isolated cross-bite. A single tooth of the top and bottom arches is in incorrect position, compromising the gum line of the lower, more narrow tooth. Isolated cases of a cross-bite, may be early signs of further underlying concerns and really should not be overlooked.

This image demonstrates a deep overbite (Class II malocclusion) in which the top teeth fully cover the bottom teeth.Skeletal assessments would be performed using another radiographic image pertinent to an orthodontist, a lateral cephalometric imae.

This image is of an anterior open bite. Your child may develop this based on genetic background or due to prolonged sucking habit once permanent teeth are coming in. You can recognize that the back molars are in occlusion, but there is a gap in the front teeth; an opening.

The final image shows an underbite. This is when the lower arch is in a more advanced, forward position than the top arch. It is clinically referred to as a Class III malocclusion.

I hope this helps you better understand why I suggest a visit with my friendly orthodontic colleague. We all share in the interest of best results for your child! Keep an eye out for the fourth blog post: “So My Child Has Cavities. Now What?”

We at Chevy Chase Pediatric Dentistry welcome your child to come in and have a look. It would be our pleasure to have you!

-Dr. Karen Benitez, DDS

Location: 8401 Connecticut Ave #650 Chevy Chase, MD. 20815
Phone: 301-272-1246