Is Fang Face tired of playground ridicule?

Oct. 1, 2000
Hygienists can play a role in uncovering any compelling smile issues that may be affecting their pediatric clients.

Hygienists can play a role in uncovering any compelling smile issues that may be affecting their pediatric clients.

Kristine A. Hodsdon, RDH, BS

At what age do children begin to notice people`s teeth? Or, more importantly, at what age do they begin to notice their own? And to what extent? How does a child`s or adolescent`s smile and oral health affect well-being and self-esteem? According to Oral Health in America: A Report of the Surgeon General (, a relationship exists between a child`s oral health and self-esteem, social interaction, and emotional state.

The report notes, "The social impact of oral diseases in children is substantial. More than 51 million school hours are lost each year to dental-related illness. Poor children suffer nearly 12 times more restricted-activity days than children from higher-income families. Pain and suffering due to untreated diseases can lead to problems in eating, speaking, and attending to learning."

Does anyone remember what names kids would come up with on the playground and at school when someone looked different? How would your "esthetic eyes" change during your dental-hygiene assessment if any of the following real-life children were your own, or were your niece, nephew, children of close friends, etc.?

Y A 9-year-old boy has huge, hypoplastic white "swirls" in the enamel of his permanent dentition and is called "Chalk Teeth" by other kids.

Y A 13-year-old girl has bilateral peg laterals and is called "Fang Face."

Y A 7-year-old girl has a single brown spot on #9, and her classmates refer to her as "Spot."

So should we be aware of the esthetic needs and concerns of small children and adolescents? Dr. Jeff T. Blank of South Carolina (, who provided me with the above examples, says, "So many kids today are teased concerning their appearance that it behooves us to master our communication skills and our conservative esthetic skills so we can nip this esteem issue in the bud."

Dr. Blank is the father of three children. His daughter, Mary Catherine, had anterior nasal stenosis, a rare bony malformation. She underwent a surgical procedure that disrupted #E and #F. He felt his daughter`s pain at the "tongues" of her classmates, and it ignited his passion for pediatric esthetic dentistry.

Hygienists can play a role in uncovering any compelling smile issues that may be affecting their pediatric clients. Many children will not volunteer their concerns, especially if they are tied to their self-esteem. Nor will they open up if they have expressed feelings in the past that have not been validated. This reluctance begins a trend that will create even more self-doubt as they get older.

Creating an environment that is "safe" and nonjudgmental will allow youths to express any concerns that they may be having with their teeth. The atmosphere should be without sarcasm. Do not say, "Do you have a date for the prom yet? Well, if Dr. Jones gets rid of those brown spots on your front teeth, you might have a chance!"

As esthetic practitioners, we need instead to employ some of the same communication principles that we use with adult clients.

For example, one might say, "Johnny, as part of the dental hygiene sessions in this office, I will be performing a smile assessment. You know that we are in the `smile business,` so it is my privilege to make sure that everyone who visits me is happy about his smile. How do you feel about your smile?" In this way, the child will likely be more relaxed, knowing that he or she is not being singled out. The child understands that all clients experience these questions and assessments.

It may take a few sessions of building rapport before the child feels comfortable enough to share any insights or answers to your gentle, open-ended queries. If it does occur, encourage this behavior and validate the concerns.

"Johnny, I appreciate you sharing with me that you are unhappy with the brown spot on your front tooth. If something could be done to get rid of the brown spot, would you be interested in hearing about it? Do I have your permission to discuss your concerns with Dr. Jones when she comes in for your examination today? Can I discuss some strategies with your parents so that we may create a win-win situation for all of us?"

The following areas may be incorporated and evaluated during the pediatric dental hygiene visit:

Y Discoloration of teeth - brown, white, yellow, and orange stain caused by developmental disturbances.

Y Trauma or medication-induced enamel hypoplasias, fluorosis, and genetic pigment distributions.

Y Congenitally missing anterior teeth.

Y Diastemas.

Y Fused teeth.

Y Malformed teeth, such as a peg lateral.

Treatment options for discoloration may be based on the pathology of the discoloration, the depth of the stain into the enamel, and the patient`s age. A cocktail of techniques include nightguard whitening, microabrasion, and resin composite veneers.

The research is not well-documented on the effect carbamide peroxide has on the development of permanent teeth. Some studies do caution that younger teeth may be more susceptible to sensitivity from the whitening agent, due to the larger pulp chambers generally found in young dentitions.

A modified version of treatment could be developed where the client is more closely monitored. The treatment could consist of a low-percentage whitening agent and a high concentrate of neutral sodium fluoride in a tray application. Or the daily protocol could be revised to every other day or every third day for treatments.

Microabrasion also can be used to eliminate enamel stains. Enamel microabrasion has become accepted as a conservative method of improving the appearance of teeth with superficial dysmineralization and decalcification defects. The procedure can be done without anesthesia and can be accomplished by chemical, mechanical, or a combination of the two methods. Microabrasion, however, can leave the tooth surface rough. In some cases, it may be necessary to place a composite resin or a veneer over the enamel surface to restore any lost contour, create the desired color, and/or a polished surface.

Additional measures that involve resin composites may be conservative bonded veneers. A conservative "no prep" approach (which assures reversibility) can be used to correct minimal malformations, as well as gross discolorations. Another approach might be modified orthodontic appliances that can be used as "fixed bridgework" for avulsed primary teeth as a "glued-in" alternative to removable dentures.

For repairing decayed or fractured teeth, instead of reaching for amalgam as a posterior restoration, another approach may be to try a polyacid-modified resin composite (compomer). Research shows that compomers can be placed without etching. For children who express an "as quick as possible" goal, this material may offer an advantage. Even though it does not have the wear resistance of other composites (normally a consideration with adult cases), compomers on primary teeth may be a nonissue. Lastly, compomers release fluoride, further benefiting a child whose self-care may be less than meticulous.

Early identification of possible behavioral inclinations suggesting future esthetic concerns should also be integrated into the hygiene assessment and self-care dialogue (with both the client and parents/guardians). Your esthetic eyes could recognize and document:

Y Clenching or grinding habits.

Y Excessive fluoride consumption.

Y A need to prescribe antibiotic tetracycline more cautiously.

Y Children who need to wear protective mouthguards.

Y The consumption of cavity-producing beverages and foods, such as soda and sugar treats.

Y Delayed eruption patterns or crowding.

"I have seen and heard so many speakers on the circuit talk of hugs, tears, gifts, etc., after an adult esthetic procedure has been done successfully," Dr. Blank says. "... But the tearful smile of a child who literally hates his or her teeth, looking in the mirror after a simple diastema closure, breaks my heart. And, of course, with my daughter, a simple bonding made her lack of a primary central incisor appear more symmetrical and gave her a renewed sense of confidence for family pictures. To my knowledge, she has never been teased or questioned about what was wrong with her teeth since."

References available upon request.

Kristine A. Hodsdon, RDH, BS, presents seminars nationally about

esthetic hygiene. Her company, Dental Essence, is based in Chester, N.H. She can be e-mailed at