Today we introduce you to Dr Amparo Perez who has been a pediatric dentist for 30 years. She treats babies and pregnant women in clinics in Spain. In addition, she coordinates a Master’s degree in integrated pediatric dentistry at the University of Murcia and is a collaborating professor COII at the Morales Meseguer Hospital in Murcia.

We are very glad to have talked to Amparo because, after this interview, we can’t highlight enough her great work, which is 100% focused on prevention, without any judgment about breastfeeding that focuses on the real cause of problems: habits.

The dental health of babies and children in regard to breastfeeding is a very controversial topic: does breastfeeding cause tooth decay?

No. Breastfeeding alone does not cause cavities. Tooth decay is a multifactorial sugar-dependent disease. Breastfeeding is actually protective against tooth decay because of the contents of breast milk, such as arginine and urea, that favor the increase of the pH of the mouth and, consequently, decrease demineralization. Or casein that favors remineralization. The studies that relate breastfeeding and tooth decay refer to prolonged breastfeeding for more than 18 months or more than 24 months. So my question is: Was there dental hygiene from the time the baby had the first tooth with toothpaste containing 1000 ppm of fluoride? Are these babies exclusively breastfed or also have solids and complementary food? Surely, the answer to these two questions is NO. I am convinced that babies can breastfeed for as long as the mother and the baby want to. The most important thing is to change habits; for example, the pregnant woman should control her consumption of sugar and avoid giving anything containing sugar to the baby in the first two years of the baby’s life. There should be a control visit to the pediatric dentist when the first tooth comes out, and the correct oral hygiene guidelines for the baby should be followed. Then, the result will be zero tooth decay.

Is breastfeeding good for the development of the baby’s mouth?

Absolutely. The baby is all instinct and for its survival, it has the oral instinct of breastfeeding (suckling). This function promotes muscular stimuli that lead to the perfect development of the jaws. When a baby takes the nipple for the first time, they learn how to breathe through the nose and to chew and swallow in the correct way. When sucking, the jaw moves forward and the mouth is closed on the nipple. When children breathe through the nose, the palate grows from the bottom to the sides, leaving the upper arch wide enough to receive the teeth. With the upper arch wide, the lower arch can move easily when chewing and allow the jaw to grow. Usually, these babies have no use for non-nutritive habits such as pacifier or finger sucking, which can cause malocclusion problems in the future.

Can breastfeeding be detrimental after a certain age?

No, at no age. There is no time for weaning. This decision should be made by the mother with her baby and, in some cases, with the pediatrician, depending on each child. Children who continue to breastfeed after the age of one, along with the nutrients from solid complementary food, receive through breastmilk more calories, more vitamins and get less sick. I am concerned about those babies who have breast milk and liquidized solid food. There are children who reach school age without eating any food in pieces. It is important to cut food into small pieces (that are not hard) according to the age of the baby, even if they do not have any teeth. You can start after six months, and this helps to massage the gums and strengthen the orofacial and maxillary muscles.

In the case of severe tooth decay, would it be advisable to stop breastfeeding?

I never recommend withholding breastfeeding. Who am I to decide for the mother and her baby? However, it is my duty to explain that the frequency of having sugar is a risk factor for tooth decay. We know that lactose is not as cariogenic as sucrose and there are even studies that say that lactose is not cariogenic in the enamel but in the dentin, but we are back to square one. This child is not only having breastmilk, but they get sugars from other foods, which add to breastfeeding during the night and surely without appropriate dental hygiene. My guidance would be that a child like this should be treated for all tooth decay lesions urgently. Have the mother try to remove or decrease breastfeeding during the night, as dental hygiene during the night is more complicated and difficult. Another important thing for all children is a regular check-up at the dentist, even more so for children who already have tooth decay at such a young age. This is a high-risk child. For mothers who do not manage to remove nighttime feeds, I recommend that you have a sterile cloth and toothpaste at the bedside table. If the child happens to wake up while breastfeeding, when you finish, take the dressing with a little bit of toothpaste and dab it onto the child’s teeth. It is okay if some of it gets stuck to the tooth. In cases where cleaning at night is not possible, do it in the morning, right after the feed, and leave some toothpaste on the child’s teeth. Only very little will be swallowed because the amount of toothpaste is minimal.

What can you tell us about pacifiers or bottles and oral health? Is there an age from which we should avoid them?

These are non-nutritional habits, and they have a negative effect. The WHO does not recommend the use of pacifiers, but in case you decide to use them, it is important to manage the frequency, which means a rational use of the pacifier. It should only be used for sleeping or when the baby is stressed. We should look for a silicone pacifier because latex causes more accumulation of bacteria. Deformations will be greater or lesser depending on the frequency, which is how many times a baby sucks per day; the intensity, which is the strength of the sucking; and the duration, which means how many months or years the baby uses a pacifier. Removal of the pacifier should be done as soon as possible, but gradually, in order to not affect the baby emotionally. Start removing it when the baby is already asleep, and avoid offering it when it is not necessary. Avoid clips to hang a pacifier on the child’s clothes.

The WHO does not recommend bottles as a way to encourage breastfeeding. Baby bottles also cause malocclusions. The effort the baby has to make when sucking at the mother’s nipple during breastfeeding is very positive because it exercises all the muscles of the face and helps the jaws to develop properly. With bottle feeding, they don’t need to make so much effort, and even less so if mothers increase the teat hole and the flow.

Another problem is when babies sleep with the bottle in their mouth and when there is no proper dental hygiene. Many so-called baby cereals also have a high sugar content, and this is also a risk for early childhood tooth decay.

Another interesting topic is tongue-tie: how can tongue-tie affect the development of the child’s mouth? What are the pros and cons of cutting it?

This is very important. Researchers around the world have proven the importance of early diagnosis and intervention of this disorder. If tongue movements are limited, they can compromise functions such as sucking, swallowing, chewing, and speaking. Ideally, all babies should be screened for tongue-tie in the maternity ward. Hopefully, one day, this will be mandatory, and midwives or pediatric nurses will be able to diagnose and successfully treat babies. Many babies have difficulties breastfeeding with possible weight loss and end up being weaned from the breast early. Many mothers have mastitis because of the difficulties these babies have in properly emptying the breast. But of course, we cannot just go out there and cut all tongue-ties. We have to follow a protocol. And that is what we do. In the master’s program, where I am one of the coordinators, we use a very simple protocol to assess, used in Brazil, where the tongue-tie test is the law. Those babies who have difficulties in breastfeeding and score on the scale are the ones where we perform tongue-tie frenectomy. There are also some cases where the baby’s score is on the scale, but the baby and the mother are fine. That is not a problem; then we just don’t do anything and keep checking on them.

Frenectomy provides immediate pain relief and weight gain for the infant in the days following the intervention because the tongue recovers its normal mobility and with it, its functionality. If we do not cut it, there is a risk of early quitting of breastfeeding.

Once the baby’s tongue-tie has been cut, are there any instructions to follow?

Yes, when we finish the procedure, we apply pressure with a gauze pad to the bleeding site and return the baby to the mother so that she can immediately place the baby to her breast. The results are often not immediate; they take a few weeks. Adverse effects only appear on rare occasions. We also advise to massage with the index finger under the tongue for about three seconds after each feed for a few days to avoid recurrence of the tongue-tie.

As parents, how can we identify if our dentist is pro-breastfeeding?

This is a question that is a little difficult to answer as a matter of ethics. What I can say is that I often get mothers with babies with early childhood tooth decay who went to other colleagues (usually not pediatric dentists). They come crying, with a huge feeling of guilt, because they were told the reason why their child has many cavities is that she is still breastfeeding. The mothers thought they were doing the best for their children. Pro-breastfeeding dentists will surely know how to act based on scientific evidence, treating the disease and controlling all the risk factors without solely blaming breastfeeding.

You have been teaching dentists and parents for many years; what is the most important thing you would like to pass on to them?

I always tell my students, the first consultation is the most important one. We should not just look at the children’s teeth and treat them. This is very easy, and we have been trained for this.

If we choose this path, we will continue to be wonderful “hole pluggers”. For me, the saddest thing is to treat a child’s mouth full of cavities and then a couple of months later, at the follow-up appointment, find new cavities. I get discouraged when this happens to me. I feel like a failure. We have to change the oral “life” of this child. This job is not easy because we have to change habits and think about the child’s home. My goal is that the children who do not have cavities remain cavity-free and the children with cavities, when the treatment is finished, will never have cavities again in their lives. And I am very stubborn. I insist and persist. 100% prevention. And to be successful I am always very clear with the parents. I tell them that if I am not going to work on their child’s mouth, it is not worth spending the money or the time. My first consultation is the one I dedicate the most time to.

You can find Ampara on Facebook: @odontopediatraamparoperez Odontopediatra Online and Twitter: Amparo Perez  @Aodontopediatra