Preparing for Your Child’s First Dental Visit

The American Academy of Pediatric Dentistry recommends that a child see a dentist by their first birthday. Some parents may feel that this is too early, and perhaps that their child is not ready for the experience or that it isn’t really necessary. No matter how many children you have had, you know that there is always a great deal to learn about each little one’s unique personality and about caring for their unique health needs. These early dental visits are much more than exams and cleanings… they play a very important role in helping your child develop attitudes and oral health habits that will ensure a lifetime of healthy smiles.

Most importantly, from the very first visit your child begins to develop a trusting relationship with the dental team in his or her new dental home; and parents have the opportunity to learn homecare techniques customized for their child.

As parents, we want to comfort our children and prepare them for new experiences, but it is very important to remember not to transfer our own anxiety to our children on the process. Remember too, that the child has no expectation that anything will hurt or be unpleasant unless someone else makes a suggestion that gives him a reason to be afraid. A first visit should be a positive, happy experience that will encourage the child to want to cooperate and return for future visits. How should you prepare your child? Here are some tips:

DO try to schedule appointments early in the day when children are well rested and not hungry.

DO explain that it is important to visit a dentist to keep our teeth healthy. There are several excellent children’s books available to help with the preparation- try bringing one home in advance to introduce the subject with your child.

DO build excitement about the experience.

DO tell the child enough that she will know what to expect: “the dentist will count your teeth, and make them shiny, and maybe take some pictures!”

DO remain calm and positive in the exam room. Provide supportive coaching for your child.

DO reward your child’s good behavior- but be understanding about what this means. A few tears are okay.

DO be firm and flexible. It is important that the dental team and the parent – not the child be in charge of the appointment. Of course, we want to do the examination and cleaning, but we don’t necessarily have to perform every planned procedure (x-rays, fluoride, etc.) for the appointment to be a success.

DO bring your child along to a sibling’s appointment so he can watch what happens before it is his turn (but make sure that the child who is being watched is not likely to cry or be upset by the procedure). However…

DON’T encourage your child to watch an adult having their teeth cleaned up-close, especially if some bleeding is likely. That can be pretty scary for children; and furthermore, an adult cleaning is usually much more involved than a child’s cleaning and therefore not a very good example of what to expect.

DON’T use words like hurt, needle, x-ray, shot, or cavity. Children are very sensitive to words that they may not fully understand and even though they had no expectation about being hurt, they will once you have use the word!

DON’T wait until there is an emergency to schedule your child’s first visit. It’s hard to have a positive when something hurts!

DON’T tease or threaten. Parents sometimes try to lighten the mood with humor, but what may seem like an obvious joke such as, “Sarah wants to have all her teeth taken out” – doesn’t seem silly or funny to a child who is confused and in a stressful environment. Children may act out because they don’t have a good way to express their anxiety…threatening to take away a privilege often has the effect of increasing anxiety and exacerbating behavior problems.

DON’T tell children that if they don’t brush their teeth they will get a cavity and have to have a shot. First of all, it isn’t entirely true. Sometimes very small cavities can be filled with no anesthetic and some may not need to be filled at all. Secondly, this well intentioned statement prepares a child to expect the worst at every visit, and they arrive fearful and less cooperative.

Every child has a different level of tolerance; his emotional and physical maturity will help guide the first dental visit. Your child will be introduced to the dental chair and other equipment, and may learn how to brush his teeth properly if he is old enough. Parents should be assisting with homecare at least until around age ten – so this visit will be educational for everyone! A cleaning is usually planned for this appointment, but it may be a scaled-down version of an adult cleaning. Depending on your child’s needs, the hygienist may just clean with just a toothbrush. Fluoride may or may not be applied, and this will largely depend on whether the child can tolerate the flavor, not swallow it, and what other sources of fluoride (supplements, water etc.) he has access to.

The dentist may ask you questions about how you care for his teeth at home, and parents should come prepared to ask any questions they may have about their child’s oral health. Finally, the dentist will check for obvious cavities or other problems. There are no definitive rules on when to take the first x-rays of a child’s teeth. As long as there are no obvious areas of concern and his mouth is large enough to accommodate the film, then two bitewings are typically taken when the first permanent molar erupts at around age six.

We understand that every child is an individual with unique needs. Sometimes, especially if there are cavities that must be filled, the most important thing to accomplish at the First Dental Visit is simply to make the child feel comfortable enough to want to come back again. Let’s begin early and work together to ensure that your child has a lifetime of happy smiles and stress-free dental visits. What techniques have worked for you to ease your child through this experience?

Childhood Dental Emergencies: What Every Parent Needs To Know

Childhood Dental Emergencies: What Every Parent Needs To Know

Childhood injuries are frightening, and certainly no one wants to see a child having pain; but in the heat of the moment it is sometimes hard to know what constitutes a dental emergency and what can wait until Monday. The truth is that it is often a judgment call, but having some guidelines can alleviate anxiety, help with on-the-spot decision making and may prevent a manageable problem from becoming a big one.

A head injury can be life-threatening and it may have resulted in a jaw or facial fracture. Both situations require immediate medical attention. Never leave a person unattended if they have suffered a head injury, and remember that the emergency medical team can often reach you faster than you can get to the hospital.

Soft-tissue injuries of the tongue, cheeks, gums, and lips are very common and they result in bleeding which is often very profuse- and very frightening – both to parents and to the injured person, making it difficult to tell how severe an injury actually is. The most important first step is to control it:

• • Rinse the mouth with a mild, warm (not hot) salt-water solution.
  • Use a moist piece of gauze or tea bag to apply pressure to the bleeding site. Hold in place for 15 to 20 minutes.
  • Hold a cold compress to the outside of the mouth or cheek in the injured area for 5 to 10 minutes. This will control bleeding and reduce pain.
  • Call your dentist right away for an evaluation; but don’t wait for an appointment if the bleeding doesn’t stop – go the hospital emergency room. Continue to apply pressure on the bleeding site with the gauze until you can be seen and treated.

  

Facial swelling is usually a sign that infection may be present and it is a true dental emergency. An abscessed tooth or other oral infection can become life threatening if left untreated. Call the dentist immediately and use a cold compress (ice or ice-pack wrapped in a cloth) on the area of swelling. Because the cold may helps keep the infection from spreading.

Toothaches have many different causes. They are not necessarily emergencies, but could easily develop into one so call your dentist as soon as possible if your child complains of pain. Over the counter pain medications that are given according to the manufacturer’s instructions may provide some temporary relief but it is important to realize that pain relief from home remedies may be masking a serious underlying problem. Never apply an aspirin or other tablet directly to the painful area because this can cause severe burns to the tissue.

A permanent tooth that is knocked out is a true dental emergency, because the faster the tooth is replaced, the better the chances that the tooth can be saved. Try to find the tooth and rinse it off gently without scrubbing any debris off of it, which can damage the surface. Never use soap or any cleaner for that matter; even mouthwash or toothpaste can be damaging! The ideal place to transport the tooth is in the mouth where it is in contact with saliva, but this may be impractical, especially if the child is likely to swallow it. Place the tooth in cold milk – never water – and get to the dentist’s office (or emergency room) immediately. Permanent teeth that are placed back in the socket within an hour have the best chance of survival.

When a baby tooth is knocked out, contact the dentist as soon as possible. Baby teeth are not reimplanted because here is a potential to damage the permanent tooth developing under it. However, the dentist may feel that it is wise to place a small device to hold the space for the permanent tooth. Furthermore, it is very important to examine the child for any fractures or oral injury that may have resulted from the trauma.

A tooth that is chipped or fractured may be an emergency, especially if the nerve has been exposed. It is a good idea to call the dentist immediately. Rinse the mouth with cool clean water and apply a cold compress to the mouth and lip if it was injured. A fracture leaves the tooth extremely sensitive to temperature change, so avoid placing ice directly on the broken tooth.

Broken braces or wires are fairly common. They seldom represent dental emergencies, but should be addressed as quickly as possible to avoid delays in treatment progress. As always, bleeding or pain is a signal to seek immediate attention. Broken wire or brackets that are irritating the cheeks, lips or tongue, should be covered with a piece of cotton or wax to protect the tissue until the orthodontist repair them. Never try to cut or remove brackets or wires, because doing so creates a risk of swallowing or inhaling these sharp objects.

Lost fillings or crowns are not usually an emergency, but you should call the dentist for an appointment as soon as possible because they can cause sensitivity. More importantly, the newly exposed tooth is particularly vulnerable to decay.

While waiting for your appointment, a loose crown can usually be slipped back over the tooth. Cement it in place using temporary dental cement (available over the counter at the drug store) which will help prevent swallowing it. Cover a lost filling with a piece of cotton gauze to alleviate sensitivity, but severe pain is a signal that there is something else going on that may require more urgent attention.

Of course, it is often said that prevention is the best medicine. Most dental emergencies can be minimized by following a few simple suggestions:

• Schedule regular dental check-ups to prevent or treat cavities early, before they cause an emergency.
• Protective gear, including a mouth guard should always be when children and teens participate in sports, and it is particularly important for children who wear braces. A custom fitted mouth guard made in the dental office provides the best protection and a new one is usually required each season because the child’s jaws are still growing and new teeth may be erupting which changes the fit.
• Always use an age appropriate car restraint – a car seat for young children and seat belts for everyone else.
• Child-proof your home to prevent falls.

When the unavoidable happens, don’t panic. Examine the child’s mouth and teeth as best you can before calling the dentist or doctor, and be prepared to answer some key questions that may be asked of you: Is there any bleeding and can you tell where it is coming from? Are there any broken or shifted teeth? Are they baby teeth or permanent teeth? Does the jaw seem to move normally when opening and closing? Tell the dentist if you are unsure of the answers to these questions so he has as many details as possible when giving a recommendation.

A good rule of thumb for both children and adults is that when in doubt, or when pain, bleeding or facial swelling are present, it is best to seek the advice of the dentist or physician right away. These are usually signs of a problem that is not likely to go away by itself; the right decisions can mean the difference between saving or losing a tooth … or even a life.

Baby Teeth are Not Just for Kids!

Parents commonly ask whether it is necessary to fill a cavity in a child’s baby tooth since they are temporary. The simple answer is YES! Baby teeth are only around for a couple of years, but they not expendable. Keeping them healthy and intact until they fall out naturally has a major impact on a child’s health and the correct positioning of permanent teeth.

A child has twenty primary (baby) teeth which form in the jaw before birth and begin to appear in the mouth at about four or five months of age… just about the time he is ready to begin tasting solid foods. These first teeth are not only important for chewing and nutrition, but for proper development of facial muscles and speech. As you might imagine, losing baby teeth too early can have long term effects, lasting well into adulthood.

Baby teeth are also space holders for the permanent teeth which are developing under the gums. When a permanent tooth is sufficiently developed, the roots of the baby tooth it will replace begin to dissolve, causing it to loosen. Gradually, the permanent tooth pushes the primary tooth out and takes its place. Occasionally a child may have a baby tooth that never develops, in which case there will usually be no permanent tooth under it either. More commonly, a baby tooth may be present but no permanent tooth has developed under it; when this occurs, many times the baby tooth roots never dissolve and the tooth is never lost. These conditions are called “hypodontia” and they rarely present major dental problems, especially when a dentist detects them early and is able to help parents plan ahead.

When a primary tooth is lost too soon, the permanent tooth has no guide to follow. To complicate matters, when there is nothing to fill the space left by a missing baby tooth, the space may begin to close causing the permanent replacement to erupt into the wrong position. The result can be crowded permanent teeth which may lead to speech disturbances and and bite problems that may require braces (orthodontics) to correct. A dentist can often prevent these complications by placing a small device called a space maintainer in the child’s mouth until the permanent tooth begins to erupt.

Sometimes, when a cavity in a primary tooth is small and the tooth is likely to be lost naturally before it causes any pain, the dentist will recommend simply “keeping an eye on it” to spare the child any discomfort from the filling procedure. Occasionally early tooth decay can even be completely repaired by just using fluoride on a regular basis. Advanced cavities must be addressed more aggressively because can be very painful for kids, just as they are for adults – they can even cause severe, life threatening infections.

Regular dental checkups are important and they can help detect small cavities early when they can be most easily repaired. Baby teeth are usually a nice, bright white color when they are healthy; so parents should be on the lookout for suspicious brown spots or other discolorations on their child’s pearly whites and be alert to signs that the child might be experiencing mouth discomfort.

The American Dental Association recommends that children have their first “well baby” dental visit before their first birthday…because preventing cavities and trauma is the best way to ensure that a child will keep his baby teeth intact until the tooth fairy is ready to claim them (rumor has it that she isn’t paying out that well these days anyway!).

February is Children’s Dental Health Month!

National Children’s Dental Health Month is sponsored every February by the American Dental Association (ADA) to raise awareness about the importance of developing good habits at an early age and scheduling regular dental visits to help ensure a lifetime of good oral health.

Whether you have kids or just love kids, there is no doubt that it can be a challenge to keep up with them. Parents understandably have many questions about caring for their children’s teeth, and with the many conflicting messages in the media it’s hard to know what’s best. Your dental health professional can help sort out all the information, but there are some important guidelines to bear in mind:

Taking care of your child’s oral health actually begins even before pregnancy!

Expectant parents should meet with their dentist and pediatrician to discuss nutritional guidelines for pregnant mothers and children, as well as important developmental milestones. Every child is different, but in general you can expect that:

• 6 weeks after conception the early tooth “bud” forms.
• 3 to 4 months gestation the hard tissue that surrounds the teeth is formed,
• Beginning 4-6 months after birth, the first baby teeth begin to erupt – often sooner for girls than for boys, and permanent teeth are already forming under the gums.
• Beginning at about age 6, the first permanent molar erupts behind the last baby tooth and soon after, the front baby teeth begin to fall out to make room for the permanent ones.

The American Academy of Pediatric Dentistry recommends that a child have their first dental office visit before age 1.

While this might seem surprising, one in four children develops a cavity before they are four years old. Your child’s oral health is influenced by many factors including the oral health and habits of the parents and siblings, genetics and diet. It’s a good idea meet with dental professionals early on to discuss potential problems before they start, and to establish a care plan for your child that includes:

• Caring for an infant’s or toddler’s mouth at home and at school
• Decisions about using fluoride
• How to manage oral habits like pacifier, finger or thumb sucking
• How to prevent and manage trauma and emergencies
• Teething and developmental milestones
• Diet and oral health

Plan ahead for bottle battles and sippy-cup strategies

Milk, formula, juice, and other drinks such as soda all have sugar in them. The more time the teeth are bathed in these liquids, the greater the risk of getting cavities. Most parents will agree that weaning children from bottles and sippy cups is easier said than done; but from an oral health perspective, it’s smart to eliminate them completely around one year- or as soon as possible after tooth eruption. The National Institute of Health suggests other strategies for minimizing risk, including:

• Don’t put children to bed with a bottle containing anything but water.
• Don’t let baby have a bottle or sippy cup to carry around between feedings.
• Don’t dip baby’s pacifier in anything sweet.

Brushing and flossing is important, but it’s not as easy as it looks!

Seasoned parents know that once children start asserting their independence, it can be difficult to convince them to cooperate with someone trying to brush their teeth. Teach children to accept help – and someone else’s hands in their mouth- from infancy. Even before the first tooth appears, it’s a good practice to remove sugars and bacteria by gently wiping the gums with a soft damp cloth after feeding. Introduce an age-appropriate toothbrush (the right size and shape) once several baby teeth have come in. Use a fluoride free toothpaste until the child can be trusted not to swallow it- and use only a pea sized drop on the brush.

It’s encouraging when a child enjoys brushing and does it often, but most children don’t have the motor skills and manual dexterity to brush by themselves until they are at least eight or nine. Until that time, they will need help and supervision. Every child is different, so talk to your dental provider to find out how your child is doing and what you can do to help.

Let’s face it- flossing is hard to do, even for grown-ups. Children have an extra hard time, because they lack the coordination to do it until they are teens. Disposable hand held floss “picks” can help, but it’s easy to misuse them and cause an injury to the gums. Let children begin practicing once their permanent front teeth erupt around age 7. Before that, and for all of the back teeth, give them a hand!

X-rays are essential. If the dentist can’t see a cavity, chances are you can’t either.

It is very common for parents to say, “My child doesn’t need x-rays. He doesn’t have any problems”, but cavities often begin between the teeth where they can’t be seen, and where the toothbrush doesn’t reach. By the time pain is felt the cavity is often big enough to require a large filling, a root canal or an extraction.

Sometimes, a dentist will recommend taking X-rays on a very young child if they are at high risk for cavities; but more often than not, children can’t hold the x-ray film or sensor in their mouth without help until they are somewhat older. This is generally not a problem, because baby teeth usually have plenty of space between them to allow the dentist to visually check for cavities.

Once the first permanent molar erupts at about age 6, spaces begin to get tighter and it’s important to take x-rays to check for cavities between the teeth. Sometimes, fluoride can heal early cavities so they don’t have to be drilled.

Furthermore, some children never develop one or more of their permanent teeth. This is rarely a major problem but it is important to know about it in advance to plan ahead for braces (orthodontics) if necessary. When no permanent tooth exists, the baby tooth doesn’t always loosen and fall out by itself. In fact, it’s very possible to keep the baby tooth in place for many years as long as it is well cared for, thereby avoiding a variety of potential complications.

Modern Dental X-rays are extremely safe, and without them your dentist has an incomplete picture of your child’s oral health. Knowing in advance what is developing under the gums and between the teeth can help avoid long term problems.

Fluoride

Fluoride is safe, effective and has been recommended by the American Dental Association for 50 years for the prevention of cavities. The dental provider may apply it during checkups in a gel, foam, rinse or varnish; and a variety of prescription and over the counter products containing fluoride are available for home use. The dentist or hygienist will provide you with individualized recommendations for your child.

The American Dental Association advises against using fluoridated water for mixing infant formula because it can damage developing tooth enamel; the local health department can provide information about water fluoridation. Parents should keep fluoride products, including toothpaste out of children’s reach and be alert for signs of fluoride overdose (abdominal pain, vomiting, and diarrhea) if they suspect a child has ingested a large amount of these products.

Sealants

Permanent molars (and sometimes premolars) develop with deep narrow grooves in them. Bacteria that cause cavities become trapped in the grooves, but toothbrush bristles are too large to clean them. A sealant is a plastic coating that is painted on to the chewing surface of to fill in the grooves and create an easily cleanable surface. The sealant can’t be applied once an obvious cavity has developed, so the dentist may recommend sealants as soon as the first permanent molars begin to erupt around age 6.

Children’s oral health is a team effort… and it’s all about prevention.

Armed with the right information and a good oral health team, teachers, parents and caregivers can help establish the foundation necessary for life-long oral health. It’s a team effort that requires a variety of different strategies from good nutrition to regular professional care.

It’s probably no surprise to hear that despite our best efforts to intervene, kids don’t always brush very well; and to make matters worse they probably (at least occasionally) eat and drink things that they shouldn’t. They fall down, they have accidents, and they are sometimes faced with oral health issues that no one can prevent or predict.

The key to a lifetime of healthy smiles in spite of it all is to have a plan in place to compensate for kids being… well, kids.

The fluoride controversy: The history, benefits and new Federal recommendations

Almost all drugs, medical products and techniques have some potential side effects, but we rarely hear much about those side effects when the risk is small or outweighed by the advantages. Fluoride is no different…we have known about its benefits for cavity prevention for nearly a century. So, why is it so controversial and what is the truth about this commonly used substance?

History of water fluoridation

In 1909 a dentist named Frederick McKay observed that some children in the Pike’s Peak region of Colorado developed a brown, mottled stain on their teeth; but despite the unattractive appearance, these children had relatively few cavities. After 22 years of research conducted by Dr. McKay and several other notable scientists, the cause of the phenomena was identified. Cryolite, an abundant mineral in the region, contains the element fluorine which was washed out during rain and snowstorms creating high concentrations (2-13 parts per million) of fluoride in the local water supply. By 1935 another researcher, Dr. H. Trendley Dean had concluded that when fluoride concentration in the water is maintained at about one part per million, tooth decay (caries) can be successfully prevented without the characteristic brown mottling of fluorosis.

Intentional fluoridation of the first U.S. public water system occurred in Grand Rapids, Michigan in 1945. The effect on the local school children was studied for 15 years and the fluoride was found to reduce tooth decay by 60%. In 1950, the American Dental Association officially accepted and encouraged the community water fluoridation as a means of caries prevention and today, about 67% of American communities benefit from this public health practice. Research has shown that as a result, the rate of tooth decay across America has been reduced by 29 % among children and 20%-40% among adults.

Benefits of Fluoride

Certain oral bacteria use the sugar and carbohydrates found in our food to produce acids that remove the minerals from the tooth. Over time, this demineralization weakens the teeth and leads to decay. Roots of the teeth, which are softer than the enamel and often exposed due to receding gums are especially vulnerable to decay and sensitivity.

Fluoride is absorbed into the enamel and root surfaces, forming a crystal that becomes part of the tooth structure, making it harder and more decay- resistant. Through this remineralization process it is actually possible to reduce sensitivity, stop the progression of early cavities and even reverse early tooth damage.

Although swallowing small amounts of fluoride is generally safe, it is not helpful. The real benefit of fluoride comes from frequent, low dose application to the surfaces of teeth that are already erupted. That is the reason it is found in so many different over the counter and prescription products, and often in the in the water supply.

The Controversy

Fluoride is an element, naturally occurring in concentrations typically too small to pose a problem- though it does accumulate in the body over time. That’s one of the reasons why it works so well to prevent cavities! On the other hand, ingesting very large quantities can be quite toxic, which is one reason why dental professionals recommend that children too young to “rinse and spit” should not be allowed to use fluoride toothpaste. Opponents of fluoridation have linked excessive fluoride intake to bone brittleness, cancer, and reproductive problems. Certainly, history has demonstrated that fluorosis (staining and brittleness) can occur when too much fluoride is swallowed during tooth development (before age 8).

Yet, the Center for Disease Control and prevention (CDC) named community water fluoridation as one of the “ten greatest public health achievements of the 20^th century”… that that doesn’t mean that it is without controversy! The reason is an ethical one: Some people argue that putting fluoride in the community water supply takes away “informed consent” and obstructs the freedom to opt-out.

Just as with any other substance that is ingested, there are some precautions that should be taken regarding fluoride use. According to a study appearing in the Journal of the American Dental Association (2008), “There is weak and inconsistent evidence that the use of fluoride supplements prevents dental caries in primary teeth. There is evidence that such supplements prevent caries in permanent teeth. Mild-to-moderate dental fluorosis is a significant side effect.” Furthermore, the ADA recommends against using fluoridated water when preparing infant formula. Always confer with a dentist and pediatrician regarding the use of fluoride supplements for infants and children.

Caregivers should contact poison control if a child ingests a large amount of a fluoride-containing product like toothpaste, and they should be alert to signs and symptoms of overdose such as nausea, vomiting and abdominal pain. Drinking milk can inactivate the fluoride in the body and slow the toxic effects of a suspected overdose.

Current Recommendations

Fluoride is still a very safe, very effective and widely used method of preventing tooth decay – approved by the American Dental Association and the Food and Drug Administration both for children and adults. Current research indicates that most children are exposed to many more sources of fluoride (such as prescription or over-the-counter dental products, fluoride-containing sealants, filling and other dental materials, foods and beverages, etc.) than they once were. As a matter of fact, we have done such a good job as a society of finding ways to make it easily available to the public that most people no longer rely the water supply as a primary source of fluoride.

As a result, the U.S. Department of Health and Human Services and the U.S. Environmental Protection Agency announced in January 2010 its recommendation to reduce level of fluoride that is added to the public water supply. The new recommendations propose that fluoride in most drinking water be set at the low end of the optimal range to prevent tooth decay (0.7 milligrams of fluoride per liter of water replaces the current recommended range of 0.7 to 1.2 milligrams). The EPA is also initiating review of the maximum amount of fluoride allowed in drinking water.

Communities always test their water to determine how much (if any) extra fluoride should be added in order to achieve the optimal safe amount. After much discourse, Long Island no longer fluoridates the community water supply, but there are hidden sources of fluoride about which consumers should be aware: private wells, springs, and water bottled in other locations – even the water in canned vegetables may contain fluoride! The USDA maintains a database with information about the fluoride content in foods, and consumers can sometimes obtain information by contacting the manufacturer.

Like almost all drugs and other substances used in medicine, the trick is to regulate the amount and frequency of exposure so that we can reap the benefits without any unwanted side effects. Dentists and hygienists make it their business to know how much fluoride is in the water in the communities where their patients live before prescribing additional fluoride-containing products. Whether we realize it or not, dental professionals have always made recommendations for fluoride use on a case–by-case basis, considering not only a patient’s level of risk for developing cavities but also their current exposure level… so, you can confidently follow your dental providers’ advice about using the fluoride products they recommend.

For more information about fluoride, ask your dentist or dental hygienist and check out the Center for Disease Control and the American Dental Association .