Dentistry for Kids. Ulrike Uhlmann

      Fig 3-6 Removed natal tooth. The mother attended the practice with the 5-day-old patient. Both mandibular lateral incisors were already present at birth, and one had already been removed by the midwife in the hospital. Removal of this tooth was done with a small bone nibbling forceps without local anesthetic. The newborn slept through the entire treatment.

      PACIFIER USE AND THUMB SUCKING

      One of the trickiest issues to navigate in pediatric dentistry is children sucking on their thumb and/or a pacifier. It starts with the question “What’s better?” The great advantage of a pacifier is surely that it can easily be removed when weaning the baby off it; the drawback is that it gets used more intensively than the thumb during the period of use.13 On the other hand, the thumb is more readily available to children than a pacifier and, unlike a pacifier, it obviously can never be taken away by a parent. Although in most cases the thumb is used for less time over the day, infants are still weaned off it much later, which can cause a number of malformations. Among 2- to 5-year-olds, thumb sucking is the most significant etiologic factor for an anterior open bite. This open bite can be symmetric or, less favorably, asymmetric. An open bite can cause speech disorders, esthetic impairments, changes in the swallowing pattern, myofunctional disorders, and difficulties in biting food with the anterior teeth.14 Obviously these anomalies can equally be caused by prolonged use of a pacifier. In answer to the question of which is preferred, use of a pacifier still tends to be preferred over thumb sucking. Regarding daily use of a pacifier, Dr Andrea Thumeyer wrote, “Use a pacifier as sparingly as a medicine.”15

      Parents often ask whether their dentist can recommend a certain brand of pacifier to minimize these potential problems. In the author’s experience, this choice only partly lies in the hands of the parents because not every child will accept every pacifier. Pacifiers with a very narrow or soft shaft are usually recommended. However, all pacifiers (whether or not they are ergonomically designed) hold the tongue away from its physiologic resting position on the palate, which inevitably will lead to malformations if the pacifier is used too frequently and/or over a long period of time. Far more important than the shape or brand is instructing parents on restricting and limiting the use of pacifiers and when to begin the weaning process. Parents should continue using smaller pacifiers because the larger the pacifier, the greater the risk of malformation. Furthermore, heavy pacifier chains should be avoided because they increase the weight of the pacifier and also the forces acting on the teeth and surrounding structures. Furtenbach answers the question about the best pacifier with: “The best pacifier is the one you don’t give to your child.”5

      Another key question is obviously when to wean children off pacifiers or thumb sucking. With regard to pacifiers, Schopf writes, “if weaning off this habit takes place by the age of 3 years, there is a significant and age-dependent increasing trend to avoidance of an open bite.”13 Weaning should thus be started around the child’s second birthday. From an orthodontist’s point of view, the pacifier should then be “disappeared.” For speech therapists, the optimum time to begin weaning is when the child starts to talk (varies between individuals, but generally between 7 and 12 months). If children are weaned off their pacifier too late, there is a risk that an open bite of the primary teeth will persist through to the mixed dentition. This is because, when they have been weaned off a pacifier, the tip of the tongue likes to occupy the space of the pacifier and the bite is no longer able to close.

      Several possible ways of weaning off a pacifier are described in the literature. Ultimately, however, success depends entirely on the parents’ persistence. It is helpful to link giving up the pacifier to a special day or holiday such as Christmas or Easter. Parents can persuade their child to give up their pacifier to a younger sibling or family member. If the parent explains that the younger child now needs the pacifier, the child may feel more inclined to part with it, now that they are more “grown up.” Another way to wean children off pacifiers is to send the pacifier to a “pacifier fairy” or hang it on a “pacifier tree.” A pacifier tree (sometimes referred to as a binky tree) is a tree that is full of old pacifiers that children have given up; these trees are usually in large cities. Parents can also trim the teat gradually or puncture it with holes to make sucking unattractive to the child. This approach works very well too.

      It is much more difficult to wean children off thumb sucking. The average age when children stop sucking their thumb is 3.8 years.16 When children are aged between 0 and 3 years, it is a good idea for parents to praise them when they do not suck on anything (positive reinforcement). Between 3 and 5 years, behavioral therapy can be attempted with the dentist’s support. In doing this, the dentist should act as an ally on the side of the child, motivating rather than scolding. Parents can also put bandages on the thumb that gets sucked. These would come off if sucked, so parents can give their child a little prize if the bandage survives the day unharmed. The process, like weaning off any other sucking habit, should be accompanied by plenty of positive reinforcement. Commercial thumb-sucking liquids as a form of a negative reinforcement should not be used