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May 2017
Volume 38, Issue 5

Toddler Oral Health: From Frenums to Pacifiers

Jade Miller, DDS

The age between one and three years old presents a unique challenge for parents and dentists alike. This is the toddler age, and it is often lost in the dental discussion, mistaken as the “preschool years.” However, it is a critical dental developmental stage between the age one dental visit and the preschool dental qualifying examination. It is around this developmental period when a child says goodbye to the pacifier.

Early Childhood Caries (ECC)

The toddler age is the time when dental caries prevalence starts to rise.1 This typically occurs due to eruption and exposure of teeth to bacteria, the dietary environment of the oral cavity, and the associated socioeconomic factors of the child.

Early childhood caries (ECC) is defined as the presence of one or more decayed lesions (cavitated or non-cavitated), missing (due to caries), or filled tooth surfaces in any primary tooth in a child under the age of six. Severe early childhood caries (S-ECC) is any sign of smooth-surface caries, in a child younger than three years of age, with DMFS score greater than or equal to 4 by age three.2

Ten percent of two-year-old children have dental caries, and when they do, there are usually more than three lesions per child.3 Overall, children not living in poverty have fewer lesions than poor children, but when they do have caries, the disease severity is similar to that of poor children.3 At five years old, 50% of children living in poverty have caries.3 ECC almost always involves the anterior teeth.3


Currently, frenums can define a time of concern in infant dental health that may affect oral health in the toddler years. Concerns include the relationship of frenums and breastfeeding; frenums and bottle-feeding and pacifier use; frenums and caries risk and plaque retention; frenums and tongue posture and speech; and frenums and mandibular position and growth. Presently, there is much discussion of frenum anatomy and methods of frenectomy/frenulotomy. Treatment of ankyloglosia by frenum release remains shrouded in controversy at the present, as ongoing research continues to raise the level of evidence for the procedure. The discussion focuses on how best to achieve physiological results for improving airway, facial growth, and craniofacial development in the toddler years.

Airway and Growth

What does the airway have to do with toddler oral health? What does it have to do with pacifiers and SIDS, or obstructive sleep apnea? The normal development of the airway is a keystone to proper oral growth. The functional matrix theory (developed by Melvin Moss, postulated back in the 1960s) confirms that the airway and soft tissue guide hard-tissue growth. As 3D imaging technology continues to improve, the research is becoming increasingly clear and abundant: the way we breathe during our growing years deeply affects how our face grows.

Orthodontic and Orthopedic Changes

General orthopedic principles of force and the control it has on growth apply to the face, oral cavity, and temporomandibular joint. Most recently, a particular focus has emerged on the effect of nonnutritive sucking habits, specifically pacifier use and the resulting functional malocclusions. Are these malocclusions the result of genetics, facial type, oral physiology, oral habits, prolonged pacifier/digit, or product design? Recently, Dogramaci et al4 studied the effects of nonnutritive sucking behaviors on malocclusions through a systematic review and meta-analysis. When compared with digit sucking, pacifier use showed less risk for an increased overjet and a greater risk for posterior crossbites.

In another study,5 only two children out of 110 using pacifiers had no malocclusion. The researchers found that those children with malocclusions were 10.7 times more likely to have posterior crossbites when they used conventional pacifiers versus orthodontic pacifiers. Anterior open bites have been known to self-correct if the habit is stopped early.6

Moms and Baby Products

Pacifiers, teethers, and sippy cups may be classified as orthodontic, truly orthodontic, reversible, soft spout, hard spout, or “patented” ergonomic designs with consumer protection and safety awareness. Which type soothes the baby and encourages good oral development at the same time?

Do baby product companies care about the increased risk of development of posterior crossbites or anterior open bites? If so, what are they doing about it? How is the dental profession getting involved?

To this end, it is up to us—the academicians, private practitioners, pediatricians, consumer advocates, product designers, social workers, insurance companies, etc—to think about and identify the challenges of treating toddler patients and to make them part of our oral healthcare focus.

About The Author

Jade Miller, DDS
President of the American Academy of Pediatric Dentistry


1. Dye BA, Tan S, Smith V, et al. Trends in oral health status: United States, 1988–1994 and 1999–2004.. Vital Health Stat 11. 2007;(248):1-92.

2. American Academy of Pedodontics and the American Academy of Pediatrics. Policy on Early Childhood Caries (ECC): Classifications, Consequences and Preventive Strategies. Revised 2014. Accessed March 24, 2017.

3. Tinanoff N, Kanellis MJ, Vargas CM. Current understanding of the epidemiology, mechanisms, and prevention of dental caries in preschool children. Pediatr Dent. 2002;24(6):543-551.

4. Doğramacı EJ, Rossi-Fedele G. Establishing the association between nonnutritive sucking behavior and malocclusions: A systematic review and meta-analysis. J Am Dent Assoc. 2016;147(12):926-934.

5. Lima AA, Alves CM, Ribeiro CC, et al. Effects of conventional and orthodontic pacifiers on the dental occlusion of children aged 24-36 months old. Int J Paediatr Dent. 2017;27(2):108-119.

6. Cozza P, Mucedero M, Baccetti T, and Franchi L. Treatment and post-treatment effects of quad-helix/crib therapy of dentoskeletal open bite. Angle Orthod. 2007;77(4):640-645.

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