Chapter 34: Raising Resilient Teeth

In which we guide children from first tooth to adulthood, recognizing that the habits of childhood become the dental destiny of a lifetime

---

Children occupy a special place in my work. Their baby teeth are temporary—I'll collect them eventually regardless—but those primary teeth matter far more than people realize. And their permanent teeth, the ones that need to last 70+ years, are forming and erupting during a critical window when habits get established and enamel is most vulnerable.

Get childhood oral care right, and you set a human up for a lifetime of healthy teeth. Get it wrong, and I'll be making many more visits than either of us would prefer.

I've watched children's oral health for countless generations. I've seen the patterns—what works, what fails, what matters more than people realize. Let me share what I've learned.

Why Children Are Different

Developing Enamel

When permanent teeth first erupt, their enamel is immature—less mineralized, more porous, more susceptible to acid attack. It takes 2-3 years after eruption for enamel to fully mature through post-eruptive maturation (continued mineralization from saliva and fluoride exposure).¹

This means newly erupted permanent teeth are at higher caries risk than mature adult enamel. The 6-year molars, 12-year molars, and other permanent teeth are most vulnerable right after they appear.

Higher Sugar Exposure

Children typically consume more frequent sugar exposures than adults:

• Snacks between meals
• Juice boxes
• Sweet drinks
• Candy and treats
• Sugar in school lunches

Each sugar exposure is an acid attack. Children's eating patterns often mean more attacks per day than adults experience.

Less Developed Manual Dexterity

Young children literally can't brush effectively. The fine motor control required for proper technique isn't fully developed until around age 8-10. Before that, adult supervision and assistance is essential—children may think they've brushed adequately when they've only done a cursory job.

A good rule: if a child can't tie their own shoes effectively, they can't brush their own teeth effectively. The motor skills are comparable.

The Oral Microbiome Is Being Established

This is something most parents don't realize: the bacteria that will populate your child's mouth for life are being acquired during early childhood.

The mouth is sterile at birth. Within hours, colonization begins. The first bacteria come from caregivers—through kisses, shared utensils, even breathing near the baby. The mother's oral microbiome has the strongest influence.⁴

There's a critical period, roughly between 19 and 31 months of age, called the "window of infectivity." This is when Streptococcus mutans—the primary cavity-causing bacterium—typically first colonizes a child's mouth.⁵ The timing and severity of this colonization strongly predicts future caries risk.

What this means practically:

• Delay S. mutans transmission if possible. Don't share utensils, don't clean pacifiers with your mouth, don't pre-chew food.
• Your oral health affects your child's oral health. Parents with high levels of S. mutans are more likely to transmit it. If you have active cavities, treating them protects your child.
• Xylitol for caregivers may reduce transmission. Some studies show that mothers chewing xylitol gum have children with lower S. mutans colonization.
• But don't panic. You can't sterilize your baby's world. The goal is harm reduction, not perfection.

The ecological perspective I've taught throughout this book applies to children too. You're not trying to eliminate all bacteria—you're trying to establish a healthy, balanced community from the start.

The Primary Teeth Matter

"They're just baby teeth, they'll fall out anyway"—I've heard this sentiment countless times, and it frustrates me deeply.

Primary teeth matter because:

1. They maintain space for permanent teeth. Early loss of primary teeth allows neighboring teeth to drift, causing crowding and orthodontic problems when permanent teeth erupt.

2. Infections spread. Abscessed primary teeth can damage developing permanent teeth below them.

3. Eating and nutrition. Children need functional teeth to eat properly.

4. Speech development. Teeth are involved in speech sound production.

5. Habit formation. The habits established around primary teeth carry into permanent dentition.

6. Self-esteem. Children with visible decay may be teased and develop negative associations with their appearance.

Age-Specific Guidance

Infancy (0-1 year)

Before teeth erupt:

• Wipe gums with a clean, damp cloth after feeding
• This establishes the habit and reduces bacterial colonization
• Gets baby accustomed to mouth care before the "opinionated toddler" phase

The breastfeeding advantage:

If possible, breastfeeding provides significant oral health benefits:

• Breast milk contains immunoglobulins, lactoferrin, and lysozyme that inhibit harmful bacteria
• The sucking mechanics promote proper jaw and palate development
• Breastfed babies have lower rates of malocclusion (bite problems)⁶
• Human milk oligosaccharides feed beneficial gut bacteria, which influences overall immune development

This doesn't mean formula feeding dooms a child's teeth—but it does mean breastfeeding, when possible, gives a head start.

When first teeth appear (usually 6-10 months):

• Begin brushing with a soft infant toothbrush
• Use a tiny smear of fluoride toothpaste (rice grain size)
• Brush twice daily
• No bottles in bed with milk or juice (nursing caries risk)

Teething:

Teething causes discomfort but is often blamed for more than it causes. Mild fussiness, drooling, and desire to chew are normal. High fever, diarrhea, and severe illness are not teething symptoms—they need medical evaluation.

For teething comfort: - Chilled (not frozen) teething rings - Clean, cold washcloths to chew - Gentle gum massage with a clean finger - Avoid teething tablets with belladonna (safety concerns) and benzocaine gels (risk of methemoglobinemia)

Toddlers (1-3 years)

This is the window of infectivity—the critical period when S. mutans typically colonizes. It's also the age when habits start forming and battles over brushing begin.

Brushing:

• Continue twice daily brushing
• Smear/rice grain amount of fluoride toothpaste
• Parent does the brushing; child can "help" but parent finishes
• Make it fun—songs, games, special toothbrushes
• Let them hold a second toothbrush while you brush with the "real" one

The brushing battle:

Many toddlers resist brushing. This is developmentally normal—they're asserting independence. But brushing isn't negotiable. Some strategies:

• Sing a consistent brushing song (predictability helps)
• Let them "brush" your teeth or a stuffed animal's teeth
• Try different positions: lap, standing behind them, lying down
• Use distraction: videos, mirrors, counting teeth
• Make it a game, not a battle
• Be firm but calm—teeth get brushed, period

Diet:

• Limit juice (AAP recommends ≤4 oz/day for 1-3 year olds)
• No sipping juice or milk throughout day—this is the "bottle walking" problem
• Water between meals
• Avoid sticky candies and fruit snacks (concentrated sugar that clings to teeth)
• Beware of "healthy" snacks that are sugar bombs (dried fruit, granola bars, flavored yogurt)

First dental visit:

• By age 1 or within 6 months of first tooth (AAP/AAPD recommendation)²
• Establishes dental home, identifies risk factors early
• Often just a "lap exam"—baby lies across parent's and dentist's laps
• Purpose is assessment and parent education more than treatment

Thumb sucking and pacifiers:

Non-nutritive sucking is normal and typically harmless before age 3-4. After that:

• Prolonged thumb/pacifier use can affect bite development (open bite, crossbite)
• Most children stop on their own
• If it persists past age 4, gentle intervention may be needed
• Better to quit pacifiers by age 3 than face orthodontic consequences later

Preschool (3-6 years)

Brushing:

• Pea-sized amount of fluoride toothpaste
• Parent still supervises and assists
• Teach spitting (children often swallow toothpaste)
• Morning and bedtime brushing

Flossing:

• Begin when teeth touch (often around age 2-3)
• Parent does the flossing
• Floss picks can be easier than traditional floss for small mouths

Diet:

• Continue limiting sugary drinks
• Be aware of hidden sugars in snacks
• Encourage water as primary beverage
• Limit snacking frequency

First permanent molars:

• 6-year molars erupt behind baby teeth (no tooth falls out for them)
• Often missed because parents don't realize they're there
• High caries risk—newly erupted, difficult to reach, deep grooves
• Consider sealants (see below)

School Age (6-12 years)

Brushing:

• Child can brush independently but parent should check
• Electric toothbrushes can help
• Timer or app to ensure 2-minute duration
• Continue emphasizing "spit, don't rinse"

Flossing:

• Transition to child doing it with supervision
• Water flossers can be easier and more engaging

Sealants:

• Dental sealants are plastic coatings applied to chewing surfaces of molars
• They fill the deep grooves where bacteria hide and brushing can't reach
• Highly effective caries prevention (80%+ reduction in treated surfaces)³
• Should be applied soon after molar eruption (6-year and 12-year molars)
• I strongly recommend sealants—one of the most effective preventive interventions available

Orthodontics:

• If braces are placed, oral hygiene becomes much more challenging
• Plaque accumulates around brackets
• Special brushes, water flossers, and possibly more frequent professional cleanings
• Higher caries and gingivitis risk during treatment
• Consider CPP-ACP (MI Paste) for additional protection

Teenagers (12-18 years)

The challenge: Parental influence wanes; peer influence rises. Many teens neglect oral care, consume lots of sugar and acidic drinks, and don't prioritize dental visits. This is often when good childhood habits fall apart—and when patterns that last into adulthood get set.

The adolescent mouth:

• All permanent teeth except wisdom teeth are usually erupted by age 12-13
• The 12-year molars are freshly erupted and vulnerable (consider sealants immediately)
• Hormonal changes during puberty can cause "puberty gingivitis"—increased gum inflammation
• Orthodontic treatment is common and creates special challenges

Motivation strategies:

Appeal to what teenagers actually care about:

• Appearance: White teeth, nice smile, attractive to potential romantic interests
• Breath: Bad breath destroys social confidence; good oral health prevents it
• Independence: Taking care of yourself is part of growing up
• Avoid embarrassment: Yellow teeth and visible decay are noticed

Don't use fear tactics—they don't work well with adolescents. Don't nag—it creates power struggles. Do make oral care supplies convenient and appealing.

The acidic drink problem:

Energy drinks, sports drinks, sodas, and even many "health" drinks are highly acidic and often high in sugar. Teenagers consume these constantly:

Drink	pH	Sugar per 12 oz
Monster Energy	2.7	54g
Gatorade	2.9	21g
Coca-Cola	2.4	39g
Red Bull	3.4	37g
Vitamin Water	3.4	32g

Each sip is an acid attack. Sipping throughout the day means continuous demineralization.

Strategies:

• If they're going to drink these, consume quickly rather than sipping
• Rinse with water afterward
• Use a straw (reduces contact with teeth)
• Better yet: water, milk, or unsweetened beverages

Sports and mouthguards:

If your teenager plays contact sports, a mouthguard is essential. Dental injuries from sports are common and often severe—knocked-out teeth, fractured teeth, jaw injuries.

• Best: Custom-fitted mouthguard from a dentist (most protective, most comfortable)
• Good: Boil-and-bite mouthguards from sporting goods stores (adequate if fitted properly)
• Poor: Stock mouthguards (loose fitting, interfere with breathing)

A knocked-out permanent tooth is a dental emergency that requires immediate action. Worth discussing with your teen before it happens.

Eating disorders:

This is uncomfortable to discuss but important. Bulimia nervosa—characterized by binge eating and purging—is devastatingly destructive to teeth. The stomach acid from repeated vomiting dissolves enamel rapidly.

Signs a dentist might notice:

• Erosion on the backs of front teeth
• Increased cavities
• Sensitive teeth
• Dry mouth
• Swollen salivary glands

If you suspect an eating disorder, address the underlying condition first. From an oral health standpoint: don't brush immediately after purging (wait 30 minutes), rinse with baking soda solution, use fluoride rinse.

Wisdom teeth:

• Third molars typically erupt 17-25
• May need extraction if impacted or problematic
• If retained, they're hard to clean and often develop caries
• Not everyone needs them removed—get an individualized assessment

The Fluoride Question for Children

This is where the fluoride controversy matters most. Children's developing teeth can be affected by both too little and too much fluoride.

Systemic Fluoride (Swallowed)

Benefit: Incorporates into developing enamel, making teeth stronger before they even erupt.

Risk: Excess systemic fluoride during enamel formation (roughly 0-8 years) can cause dental fluorosis—white spots or, in severe cases, brown mottling.

Sources:

• Fluoridated water (0.7 ppm in US)
• Swallowed toothpaste
• Fluoride supplements (by prescription)

Topical Fluoride (Contact with Erupted Teeth)

Benefit: Creates fluorapatite in enamel surface; accelerates remineralization.

Risk: Minimal from appropriate use.

Sources:

• Fluoride toothpaste
• Fluoride rinses
• Professional fluoride applications

Practical Guidance

If you have fluoridated water:

• Use fluoride toothpaste in age-appropriate amounts
• Supervise brushing to minimize swallowing
• No supplements needed
• Some fluorosis risk, but usually mild and cosmetic

If you have unfluoridated water (well, RO system, etc.):

• Fluoride toothpaste is more important
• Consider discussing supplements with pediatric dentist
• Professional fluoride varnish applications more valuable
• Monitor for caries development

The RO system you mentioned: Your children aren't getting systemic fluoride from drinking water. This makes:

• Fluoride toothpaste use more important
• Professional fluoride applications more valuable
• Possibly worth discussing supplements with a dentist
• Not a crisis, but worth awareness

The Swallowing Problem

Young children often swallow toothpaste instead of spitting it. This is why:

• Use only a rice grain/smear amount until age 3
• Use pea-sized amount ages 3-6
• Teach spitting early
• Don't use "tasty" toothpastes that encourage swallowing
• Supervise brushing

Diet: The Hidden Battlefield

Sugar frequency matters more than total amount. Five small sugar exposures (candy, cookie, juice box, soda, sweet snack) create more acid attacks than one larger dessert.

Teach children:

• Water is the default beverage
• Juice is a treat, not a daily drink
• Candy happens, but preferably with meals or in limited time windows, not spread throughout the day
• If you're going to have sweets, eat them and be done—don't stretch it out

School challenges:

• Pack water, not juice boxes
• Limit sweet snacks in lunches
• Chocolate milk at lunch is a sugar exposure
• After-school snacks should be low-caries risk when possible (cheese, vegetables, nuts)

The bedtime bottle disaster:

• Putting a child to bed with a bottle of milk or juice is extremely cariogenic
• The liquid pools around teeth while saliva flow is reduced
• "Baby bottle tooth decay" devastates primary teeth
• If a bottle is needed for comfort, it should contain only water

Building Lifetime Habits

The habits established in childhood tend to persist. A child who grows up brushing twice daily, flossing, seeing the dentist regularly, and limiting sugar will likely continue those patterns as an adult.

Make it normal:

• Oral care is just what we do, not a negotiation
• Parents model good behavior
• Regular dental visits from early age normalize them

Make it achievable:

• Age-appropriate expectations
• Don't expect perfection
• Praise effort and consistency

Make it positive:

• Not a chore, just part of the routine
• Celebrate dental visit success
• Don't use dentist as threat ("brush or the dentist will drill your teeth")

Children with Special Needs

Children with developmental disabilities, chronic illnesses, or other special needs often face additional oral health challenges:

Physical challenges:

• Limited motor control makes brushing difficult
• Oral defensiveness (hypersensitivity) may cause resistance to brushing
• Positioning may be difficult (wheelchairs, muscle tone issues)
• Certain medications cause dry mouth or gingival overgrowth

Behavioral challenges:

• Difficulty understanding instructions
• Anxiety about dental procedures
• Inability to cooperate during examination
• Sensory processing differences

Strategies that help:

• Desensitization: Gradual introduction to oral care tools and sensations
• Visual schedules: Pictures showing the brushing sequence
• Adaptive equipment: Large-handle brushes, electric brushes, suction brushes
• Positioning: Adaptive chairs, lying across a bed, sitting in a beanbag
• Distraction: Music, videos, favorite objects
• Consistency: Same time, same routine, same place every day
• Caregiver support: Parents may need to assist with brushing into adulthood

Finding appropriate care:

• Pediatric dentists often have training in special needs
• Hospital-based dental programs may offer sedation or general anesthesia when needed
• Don't give up if one provider isn't a good fit—keep looking
• Many children with special needs can receive care in a regular dental setting with appropriate accommodations

The goal remains the same: protect the teeth these children will need for their entire lives. The methods may need adaptation, but the importance is if anything greater—dental treatment requiring sedation or anesthesia carries risks that prevention avoids.

When to See a Specialist

Pediatric dentists specialize in children's oral health. Consider them for:

• First dental visit
• Children with anxiety about dentists
• Children with special needs
• Complex treatment needs
• If regular dentist isn't comfortable with young children

Orthodontic evaluation typically recommended around age 7 to identify developing problems, even if treatment won't happen until later.

Emergency situations:

Know what constitutes a dental emergency:

• Knocked-out permanent tooth: Time-critical emergency. Rinse tooth gently (don't scrub), place back in socket if possible or keep in milk, get to dentist immediately. The tooth can often be saved if reimplanted within an hour.

• Broken tooth: See dentist same day if possible, especially if there's pain or the nerve is exposed (pink or red visible at fracture site)

• Severe toothache: Indicates infection or pulpal involvement—don't delay
• Swelling: Can indicate spreading infection—seek care promptly
• Bleeding that won't stop: After injury or extraction, sustained bleeding needs attention

What I Wish Every Parent Knew

After watching countless children's teeth, here's what matters most:

1. Primary teeth matter. Don't dismiss them as temporary.

2. Supervise brushing until age 8-10. Children cannot do it effectively alone.

3. Fluoride toothpaste from first tooth. The benefits outweigh fluorosis concerns with appropriate amounts.

4. Limit sugar frequency. It's the pattern, not just the quantity.

5. Get sealants. On 6-year and 12-year molars. Highly effective, underutilized.

6. Establish dental home early. First visit by age 1.

7. Water, not juice. As the default beverage.

8. Never bottles in bed with anything but water. This single practice prevents enormous suffering.

Your children's teeth are my future workload—or not. The habits you establish now determine whether I'll be collecting their teeth for decades to come or whether they'll keep them for a lifetime.

Every tooth I have to collect is a small tragedy that pulls me away from work I'd rather be doing—tending my garden, studying the herbs, teaching those who want to learn. Help me get back to that. Keep your children's teeth where they belong.

---

---

1. Tooth enamel — Wikipedia. Post-eruptive maturation continues for 2-3 years after tooth eruption, making newly erupted teeth more caries-susceptible. ↩

2. American Academy of Pediatric Dentistry. (2021). Periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. The Reference Manual of Pediatric Dentistry. ↩

3. Ahovuo-Saloranta, A., et al. (2017). Pit and fissure sealants for preventing dental decay in permanent teeth. Cochrane Database of Systematic Reviews, (7). CD001830. ↩

4. Lif Holgerson, P., et al. (2015). Oral microbial profile discriminates breast-fed from formula-fed infants. Journal of Pediatric Gastroenterology and Nutrition, 60(4), 474-482. ↩

5. Caufield, P. W., et al. (1993). Initial acquisition of mutans streptococci by infants: Evidence for a discrete window of infectivity. Journal of Dental Research, 72(1), 37-45. ↩

6. Peres, K. G., et al. (2015). Effect of breastfeeding on malocclusions: A systematic review and meta-analysis. Acta Paediatrica, 104(S467), 54-61. ↩