Baby teeth: Wait for them to fall out naturally or get them pulled?

When it comes to baby teeth, it is generally best to wait for them to fall out naturally rather than getting them pulled. Baby teeth play an essential role in guiding adult teeth into place and helping the jaw and other facial structures develop[1]. Removing a tooth too early could lead to crooked adult teeth and other dental problems later on[1].

A baby tooth will usually begin to wiggle when its soft roots start to dissolve, and when they have fully disintegrated, the tooth will fall out naturally[2]. It is completely fine for a child to wiggle their loose tooth with their tongue to hasten the process[2]. However, if a tooth is only slightly loose or causes pain when touched, it could indicate that the underlying roots are not dissolved enough to safely remove it[1].

In some cases, a pediatric dentist may recommend a tooth extraction if the baby teeth are not falling out prior to adult teeth coming in, or if there is an infection or severe decay[3][9]. A simple tooth extraction can be done by a pediatric dentist and involves gently loosening the visible baby tooth and pulling it, using only a local anesthetic[3]. However, tooth extraction should always be a last resort when other options are exhausted[12].

Do know that baby teeth serve many important functions

Humans are born with two sets of teeth and all the primary teeth are eventually replaced by permanent teeth. Because of this, baby teeth play a valuable role in maintaining the space for the adult teeth as your child grows. Primary teeth are also important for general growth, speech development and nutrition. Therefore, it’s important to keep your child’s baby teeth healthy, and to keep them in his mouth for as long as possible until they are ready to fall out naturally.

Do know that there are some instances when primary teeth should be removed

Although baby teeth play an important role in your child’s growth, there are many reasons your child may need to have them extracted early.

Extraction may be indicated due to a bad toothache, severe decay or infection, trauma or some disturbances in the growth pattern or normal shedding schedule of the tooth. Sometimes the decision to remove a tooth may be not due to a problem with the tooth itself, but the fact that its removal is beneficial to the surrounding teeth; such is the case when a stubborn primary tooth keeps the permanent tooth from coming in properly.

Additionally, an orthodontist may want tooth to be removed to accelerate the start of orthodontic treatment. Though the general goal is to try to preserve the baby teeth, some factors make it impossible or less beneficial to do so. Your dentist should be the one to give you treatment options and help you make the best decision.

Do be familiar with the all-common “shark teeth” syndrome

Normally, as a permanent tooth grows and erupts into your child’s mouth at around 6 years old, the baby tooth will become progressively looser until it falls out. Sometimes this doesn’t happen exactly as planned, and the permanent tooth may appear before the primary tooth is lost. This will present as a double row of front teeth in your child’s mouth and is sometimes referred to by parents as “shark teeth.” This is one of the most common dental concerns that pediatric dentists encounter from parents and, while it should be addressed, is not an emergency. Extraction is generally the correct treatment for this problem, but the timing of treatment and whether it is necessary is determined by which arch (top or bottom) is affected and the nature of the situation.

When it happens to the front incisors in the bottom arch, often the condition will resolve on it’s own without needing intervention, especially if the new tooth has not come in completely and the primary tooth is quite loose. If the permanent tooth continues to grow and the baby tooth remains solid with no mobility then your dentist will most likely extract the tooth. As long as there is space for it, the adult tooth will migrate into a more correct position over time. When your child has an over-retained incisor on the top arch, it is best to extract the baby tooth immediately (even if it is loose) in order to prevent the adult tooth from coming in at an improper position or being stuck behind, or in crossbite with, the lower incisor. As your child gets older, he may also encounter over-retained teeth in the molar area. Again, it is best to have a dentist evaluate the situation to determine whether to treat it.

Do be calm and know what to expect during and after the procedure

If an extraction is recommended for your child, the first thing you should do is be calm so that you don’t transfer an unnecessary anxiety or fear to your child. Be honest with him about what will happen but it’s best to avoid scary words such as “pull” or “needle.” Your dentist will have a consultation with you so that you understand what will happen the day of the procedure. Your dentist may administer local anesthesia and even nitrous oxide (laughing gas) so that your child is comfortable during the extraction. Profound anesthesia should eliminate pain completely but it does not remove the pressure stimulus. If the tooth is a “hot tooth” due to severe infection, it will be more difficult to achieve profound anesthesia with even the maximum amount of local anesthetic allowed. As a result, your dentist may prescribe antibiotics for your child to begin taking a few days before the procedure.

After the extraction, your child should remain in the office until hemostasis is achieved and there is minimal bleeding at the site. Post-operative instructions will be given to you both verbally and written and will include instructions on dietary and activity precautions, how to care for the site, and recommendations for pain relief. An important thing to note is that the area may remain numb from the anesthetic for a few hours and your child should be cautioned against biting, sucking or playing with the area until all sensation returns. This is important in order to avoid tissue damage until the anesthesia wears off. Your dentist will also specify whether your child should return for any post-operative visits.

Do know that follow-up treatment may be required

If your child must have a baby tooth removed early, your dentist may want to maintain the space so that the adjacent teeth do not drift and block out the adult tooth that will replace it. There are several factors that determine whether space maintenance is necessary, including: the age of your child, the presence or absence of an adult tooth to replace the baby tooth, how long it will take for his adult tooth to come in, which baby tooth need to be pulled, and whether there is a lot of space or crowding in your child’s mouth. There are various types of space maintainers available and your dentist should discuss the treatment plan with you prior to extracting the tooth so that you are aware of everything to expect in the days, months and years following the extraction.

Do not think that extractions are a quick fix

Some parents are under the impression that when there is a problem with a baby tooth it should be pulled just “because it’s a baby tooth and it will just fall out anyway.” However, as discussed before, baby teeth serve many important functions for your little one and removing them prematurely may possibly lead to complications in the growth and position of the associated permanent teeth. Furthermore, the tooth that normally replaces it may even be absent, causing more long-term issues for your child. Thus, extracting a baby tooth may temporarily help relieve any pain your child may have, but it is important to think about overall picture of his health as he grows and develops.

Do not diagnose on your own

A dentist is the expert for making the decision about whether a tooth should be extracted. The treatment decisions will be based on a various number of factors and take into account the short and long-term consequences of doing so. These factors will include your child’s age and dental development, the ability to restore the tooth and its prognosis, how close the tooth is to coming out naturally and whether the associated permanent tooth is present or absent.

Several diagnostic aids will be necessary to diagnose your child, especially an x-ray of the tooth. The radiograph may either be an intraoral photo such as a periapical or bitewing, or an extraoral photo such as a panoramic x-ray. A pediatric dentist has had specialized training in the eruption sequence of primary and permanent teeth as well as their relation to each other and is more likely to treat based on the whole picture and how the treatment will affect your child as he grows. Therefore you may want to take your child to a pediatric dentist for the best care possible.

Do not think that the extraction of baby teeth will fix crowding

It is a common scenario, especially in the front teeth, for a child to lose his primary incisor only to have the permanent incisor come in much larger, and in a position where there is not enough room for it to fit into the arch. A common misconception is that the removal of the adjacent baby tooth will make room and allow for the adult tooth to come in straight. In most cases, the extraction will not correct the situation that started it. In fact, the extraction of baby teeth generally never corrects crowding alone. Your child likely has inherent crowding and will probably need orthodontic treatment by way of expansion or the extraction of permanent in order to ultimately correct the crowding.

Do not think that all baby teeth that need to be pulled are problem teeth

Sometimes it’s the permanent teeth that are the problem. They may develop in a poor position, making it likely for them to either grow in abnormally or become impacted and “stuck” in the bone. Your dentist can detect a problem with certain x-rays early, even years before they grow in. Radiographs such as a panoramic x-ray show all the teeth, including the ones that are still developing and not yet present in the mouth. A Cone Beam CT scan gives even more information, as it is a 3-D image of the area.

One of the most common teeth that are likely to present in a poor position is the upper permanent canine. Your dentist may recommend the removal of a baby tooth in order to help the associated and poorly positioned permanent tooth come in at a better position. In fact, extracting a primary tooth at the right time may even prevent lengthy orthodontic treatment or surgery in the future. In this case, extraction therapy is considered preventive and beneficial because the extraction of a healthy baby tooth may prevent future problems in the adult tooth.

Do not think that your dentist will be able to treat every tooth that should be pulled

While your dentist is qualified to recommend and do extractions, each case will vary. Most of the time your dentist will choose to extract the tooth herself. However, in some cases she may refer your child to a specialist such as an oral surgeon to do the procedure. She may feel that the extraction is more difficult due to several complicating factors such as fractures, severe decay, or variations in the normal anatomy of the tooth. Oral surgeons are also able to safely sedate your child in order to make him more comfortable if his is very young, highly anxious, or if the procedure will be more extensive than usual.

Rest assured, your dentist’s decision to refer will be done so with your child’s well-being in mind. Additionally, your dentist may want an evaluation from an orthodontist, who specializes in the evaluation and correction of dental malocclusions. Coordinating treatment with an orthodontist is sometimes necessary in order to achieve the best long-term result, especially if your child has any complicated issues such as congenitally missing teeth or severe crowding.