BTX and mouthguards – the surprising answer to bruxism treatment?

Lady suffering from bruxism

From burnout to physical and mental stress, we can all agree that the pandemic has brought about some undesirable trends and side effects. In dentistry, we’re seeing a rise1 in bruxism, a condition in which you involuntarily grind or clench your teeth. 

It is not uncommon to grind or clench your teeth from time to time, especially during sleep; however, did you know that regular teeth grinding can cause damage to your teeth and even alter your face shape as the years go by? 

While teeth grinding is often attributed to stress2, it can also be associated with sleep issues and may be an indicator of obstructive sleep apnea.

In this article, allow me to explain the functional impact of bruxism, why it’s important to correct teeth grinding and the role of botox and mouthguards as treatment options. 

How can I tell if I grind my teeth at night? 

Most people are not even aware they grind their teeth until someone tells them or if they come in for a dental visit. As dentists, we can tell if someone is a clencher or grinder just by examining their mouth and jaw. 

If you experience the following signs and symptoms, there’s a high possibility you grind your teeth and should see a dentist ASAP: 

Can teeth grinding affect your face shape?

When we grind our teeth, we actively engage our masseter muscle (located near your outer cheek and jawline), causing the muscle to grow and become visibly bulky over time. Think of it building muscles in your body with repetitive exercise – except with bruxism, because it is unintentional, it can be hard to stop. 

It’s been found that bruxism can result in an increasingly square or masculine jawline3. In addition, the pressure placed on the joints can result in temporomandibular joint (TMJ) issues.

Grinding teeth vs clenching teeth (Bruxism)

So what’s the solution? 

We often correct bruxism with; 

Mouth Guards 

Mouth Guards are dental devices that protect and cover your tongue, gums and cheeks from trauma caused by teeth grinding or sports injuries. Wearing a mouthguard while you sleep can help keep your top and bottom teeth separated so they don’t damage each other from the pressure of grinding or clenching.

There are three main types of dental mouthguards, each serving different purposes:

Boil-and-bite mouthguards
- Made from thermoplastic material 

- Usage involves boiling the mouthguard until it softens and then placing it over your front teeth and biting down 

- Not recommended for long term use as it is not made specifically for the shape of your teeth and can cause your bite to shift 
Suck down mouthguards
- Created in a dentist’s office 

- Involves taking a physical or digital impression of your teeth and it comes with different thickness and hardness 

- Much more comfortable.
Hard night guards
- Made from acrylic and used to treat TMJ and severe teeth grinding and clenching 

- As the masseter muscles relax, the lower jaw also relaxes and positions itself to where it’s supposed to be 

- Extremely durable 

- May be thick and uncomfortable
Mouth Guards for Bruxism


While mouth guards can prevent tooth damage, it does not solve the root of the problem – which is the involuntary grinding and clenching. 

This is where I highly recommend Botox4. It’s been clinically proven5 that BTX is a safe and effective treatment for teeth grinding, especially for patients with severe bruxism. 

root of the problem bruxism
Source: Dr Seah Tian Ee of TES Clinic

Many patients who do neurotoxin treatment for their bruxism end up with a slimmer lower face – this is because their overworked masseter muscle shrinks back to its original size, resulting in a smaller and slimmer facial appearance.

As an added benefit, the symptoms that present with teeth grinding also reduce or dissipate. And don’t worry – while your masseter muscle is significantly relaxed, you can still smile and chew as per normal. 

At An Dental, we are committed to caring for more than your dental health. That’s why our Dento Facial Esthetics service was conceived – a series of procedures that combine cosmetic dentistry and aesthetic medicine to ensure you look good and feel good. 

Whether it’s correcting functional changes or beautifying your smile, our team of dental surgeons will work with you to ensure your facial features match your teeth. 

Contact us if you have any questions! 

*Written by Dr Marlene Teo and Dr Mabel Chan


  2. Lavigne, G. J., Khoury, S., Abe, S., Yamaguchi, T., & Raphael, K. (2008). Bruxism physiology and pathology: an overview for clinicians. Journal of oral rehabilitation, 35(7), 476–494.
  3. Aguilera, S. B., Brown, L., & Perico, V. A. (2017). Aesthetic Treatment of Bruxism. The Journal of clinical and aesthetic dermatology, 10(5), 49–55.
  4. Asutay, F., Atalay, Y., Asutay, H., & Acar, A. H. (2017). The Evaluation of the Clinical Effects of Botulinum Toxin on Nocturnal Bruxism. Pain research & management, 2017, 6264146.
  5. Fernández-Núñez, T., Amghar-Maach, S., & Gay-Escoda, C. (2019). Efficacy of botulinum toxin in the treatment of bruxism: Systematic review. Medicina oral, patologia oral y cirugia bucal, 24(4), e416–e424.

Is there a connection between COVID-19 and gum disease?

By now, you must be tired of hearing the same old COVID-19 narratives and its long term effects on our health. As of now, we know that only a small percentage of COVID-19 cases turn critical, and the presence of conditions such as diabetes, hypertension, obesity, asthma, and more1 has been linked to severe coronavirus-induced conditions like pneumonia, acute respiratory distress syndrome (ARDS), multiple organ dysfunction, and even death.

Interestingly, did you know that the factors associated with gum disease are likewise related to the progression of severe coronavirus disease? 

The belief is that since inflammatory and dysbiotic factors, as well as comorbidities, affect our bodies’ systemic health, bad periodontal health can indicate impending COVID-19 complications.

Similarly, here are some crucial findings2 by researchers from McGill University:

What does this mean for those with gum disease and test positive for COVID-19? Allow me to explain further.

First, what is gum disease, or PD?

Illustration of different type of gum disease

Gum disease or periodontitis (PD) is a severe gum infection that can lead to tooth loss and other serious health complications. Periodontitis, which falls under the umbrella of gum disease, is a serious gum infection that when left untreated, damages both the soft tissue and bone that supports your teeth.

Periodontal diseases refer to a group of chronic inflammatory diseases, including gingivitis and periodontitis. The condition is associated with the following risk factors such as:

PD and severe COVID-19 illness seem to share similar risk factors! Most comorbidities (the presence of multiple conditions in your body) and risk factors reported in cases of severe COVID-19 seem to also aggravate the development of PD.

What are these common risk factors?

Shared risk factors between gum disease and severe COVID-19 illness


Ageing is a degenerative process that can lead to various autoimmune, infectious, or inflammatory conditions, including gum disease. According to the World Health Organisation (WHO), PD mainly affects adults above the age of 65, as this demographic commonly presents with these additional risk factors:

Clearly, ageing is a risk factor in linking PD and severe COVID-19 complications.


Interestingly, various studies have suggested that men are more prone to severe forms of PD than women, due to differences in immune response and function, behaviour, environmental factors, and more.


Unsurprisingly, obesity is one of the highest risk factors when it comes to developing PD. The main consequence of obesity is systemic inflammation as:

Additionally, increased inflammatory factors reported in obesity also contribute to amplifying the risk of developing severe COVID-19. It is, therefore, possible that those with the conditions of obesity and PD are at an increased risk of developing severe COVID-19 complications.


Smoking is a major risk factor when it comes to developing PD, and affects the progression, severity and response to treatment of this condition.

Smoking also causes an individual to be 1.4 times more susceptible to severe COVID-19 symptoms. What this means is like obesity, it is also possible that those who smoke and have PD are at an increased risk of COVID-19 complications.

Are there other connections between COVID-19 and gum disease?

There are also less inconclusive studies that suggest the following –which are strongly associated with PD– might be contributing factors to the prevalence of COVID-19:


Studies over the last few years suggest the vulnerability of pregnant women to PD due to an affected inflammatory response. Furthermore, it has been established that increased progesterone levels in pregnant women trigger the gingival response causing dysbiosis.

Concluding the connections between COVID-19 and gum disease

There is initial evidence that suggests that PD is a risk factor for COVID-19, especially since PD is widely associated with several conditions such as diabetes, old age, and asthma, and is indicative of our overall systemic health. 

Periodontitis is also associated with a higher risk of ICU admission, need for assisted ventilation, and even death in COVID-19 patients3.

PD also contributes to a large inflammatory load on the body and removing this inflammatory burden from your system is always a good idea! Thus, I would say that treating gum disease is imperative; Covid-19 or not! However, considering the initial studies between COVID-19 and periodontal disease, it is now more important than ever to schedule an appointment with a periodontist, especially if you experience symptoms such as:


  1. Pitones-Rubio, V., Chávez-Cortez, E. G., Hurtado-Camarena, A., González-Rascón, A., & Serafín-Higuera, N. (2020). Is periodontal disease a risk factor for severe COVID-19 illness?. Medical hypotheses144, 109969.
  3. Marouf, N., Cai, W., Said, K. N., Daas, H., Diab, H., Chinta, V. R., Hssain, A. A., Nicolau, B., Sanz, M., & Tamimi, F. (2021). Association between periodontitis and severity of COVID-19 infection: A case-control study. Journal of clinical periodontology48(4), 483–491. 

Dr. Nicole Ann Lee: What is “growth modification”, the interceptive option all parents with young children should be aware of?

It’s always better to be early than late – and this saying applies for treating your child’s teeth too. Previously, I shared the impact tooth decay in baby teeth can have on adult teeth - the gist is that baby teeth pave the way for adult teeth, and good oral habits since young are essential if you want your child to have a beautiful set of teeth. 

But apart from the usual brushing and checking of cavities, did you know that paediatric dentists can also guide the growth of a child’s jaws? This is through a procedure known as growth modification. This allows us to minimize or in some cases even preliminarily rectify common orthodontic problems such as harmful crossbites, teeth crowding, excess spacing, jaw growth discrepancies or protruding teeth. 

Please allow me to explain the importance of growth modification for growing children, and signs that your child may benefit from it!

What is growth modification?

Illustration of Growth modification

As its name suggests, “growth modification” alters the growth of the jaw bones during the child’s active growing period. Children typically get their first few permanent teeth between 7-8 years old - this period is when you want to be extra active with your child’s dental visits, as it is when we can determine if there are signs of over- or under-development of your child’s jaws and bite. 

If your child has been diagnosed with such issues, we may attempt to lessen the severity of or even correct this skeletal imbalance, which potentially reduces the need for orthodontic treatment (in the form of braces) or perhaps even orthognathic surgery down the road.

Think of it as planting a garden - in order for the trees and flowers to grow properly, we must first ensure the seeds are scattered nicely in place. Likewise, for teeth to erupt beautifully, we must catch discrepancies early and gradually make adjustments so that teeth can fit into the mouth and jaw correctly.

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What is the difference between “growth modification” and “interceptive orthodontics”?

You may sometimes come across these two terms. Growth modification is actually a subset of interceptive orthodontics. 

Depending on whether the problem lies only in the teeth positions or jaw positions or both teeth and jaw positions, various options best suited to help correct each individual case are available.

Type of interceptive treatment (ie. fixed or removable) and duration of active treatment may also vary subject to the complexity of your child’s case and age of your child. 

Most of the time, interceptive orthodontic treatment done at this stage has specific primary goals that may differ from that of comprehensive orthodontic treatment done at a later stage of life. It takes into consideration the growth tendency of the child, based on what is found clinically and radiographically during your consultation/examination visit as well as family history such as that of their siblings, parents or relatives.

What can growth modification correct?

The main benefit of growth modification is early intervention that could stave off your child needing more long-drawn complex treatments later on in their life. These treatments are usually meant to help with issues such as: 

Overbite or “bugs bunny teeth” or “protruding upper jaw”

Top front teeth extend beyond the bottom front teeth, resulting in abnormal tongue placement. 

Underbite or “protruding lower jaw”

Lower jaw juts out past the top front teeth, affecting facial shape and impeding speech.


Upper teeth fit inside of lower teeth, impacting facial symmetry. 

Open bite 

Upper and lower teeth do not touch when the jaw is closed, causing pain and oral hygiene issues. 

Other benefits include:

How is growth modification treatment carried out in Singapore?

Each dentist may do things differently but generally growth modification at our clinic involves a detailed comprehensive consultation and examination. This involves: 

Once we’ve weighed and discussed options (together with the child if he’s old enough), we can start treatment. The number of treatment sessions and appliance(s) used will depend on factors like your child’s age, teeth condition and compliance. 

Some appliances we may use include:

Facemask therapy

To stimulate upper jaw growth and correct underbites caused by a small upper jaw

Little boy with mouthguard (Growth Modification Device)

Twin block

To promote lower jaw growth and correct overbites caused by a small lower jaw

Palatal expander

Palatal expander

To correct crossbites and overcrowded teeth by gradually widening the width of the jaw

How a Growth Modification Device works (in orthodontics)

How a Growth Modification Device works (bottom view)

They may sound scary, but don’t worry - when done in the hands of an experienced and nurturing orthodontist or paediatric dentist, the process can be very safe and even enjoyable for your child!

Family Dentistry at An Dental

Misconceptions Of Growth Modification Treatment in Singapore

Some parents might have the mindset of, “Since my child’s teeth will change anyway, there isn’t a need to spend so much time and money on them now.”

To add on, some orthodontists may prefer to push back the procedure by a few years to sort the patient out when he/she is in full permanent dentition instead of a mixed dentition after growth has tapered down.

However, if you know there is already a tendency towards a discrepancy, why not give it the chance to perhaps be reduced or corrected at the early stages? With interceptive treatment done right, we could potentially help reduce the complexity of future treatment needs. 

Several studies1 have also demonstrated the importance of early intervention. In a particular cohort2 study which followed children who did growth modification treatment in their early dentition stage, almost half had incisor crowding before treatment but 98% showed good alignment of their incisors several years later.

Signs Your Child May Need Interceptive Orthodontics

Here are some signs that your child may require interceptive treatment:

Do you have any concerns about interceptive treatment or think your child could benefit from this procedure? Feel free to drop me a message and I’ll be more than happy to help! 


  1. Tzemach, M., Aizenbud, D., & Einy, S. (2014). Refu'at ha-peh veha-shinayim (1993), 31(1), 25–61.
  2. Keski-Nisula, K., Hernesniemi, R., Heiskanen, M., Keski-Nisula, L., & Varrela, J. (2008). Orthodontic intervention in the early mixed dentition: a prospective, controlled study on the effects of the eruption guidance appliance. American journal of orthodontics and dentofacial orthopedics : official publication of the American Association of Orthodontists, its constituent societies, and the American Board of Orthodontics, 133(2), 254–328.e2. 

Dr. Nicole Ann Lee: Can teeth whitening kits be trusted?

Before After using Teeth Whitening kit

When you smile, the world smiles back at you.

This old adage isn’t just an airy-fairy saying - Studies[1] show that happy smiley faces have a strong motivational effect on others, and that those who come across as cheerful tend to enjoy more social interaction than their long-faced peers. At the workplace, presentable teeth are thought to be a requirement for prestigious roles in many professions.

So, if your discoloured smile has been costing you your confidence and relationships either in or out of work, you’re not alone.

For those looking to brighten their smile at their own time, a home teeth whitening kit is convenient, readily accessible, and can usually be affordably purchased either online or over the counter. And if you’re considering using one, you’ll want to do so without any regrets or complications.

Can OTC teeth whitening kits be trusted? Here’s why we don’t think so.

How does teeth whitening work?

The human tooth contains substantial amounts of hydroxyapatite. The inner part of a tooth (dentine) contains about 70% hydroxyapatite, while the outer part of a tooth (enamel) is about 97% hydroxyapatite.

The original colour of pure hydroxyapatite is a colourless white. Consequently, natural enamel has a white colour with some translucency. However, due to long-term chemical and mechanical wear, the enamel in our teeth eventually becomes thinner and more translucent, exposing more of the yellowish dentine layer, which can in turn make teeth look stained or discoloured.

What kind of stains do you have? Tooth discolouration can be categorised into 2 main groups:

Intrinsic staining

This is attributed to factors such as genetics, age, use of antibiotics, high levels of fluoride, developmental disorders, and more. It can start before the tooth has erupted.

Extrinsic staining

This is largely due to environmental factors like smoking, pigments in food and drink, antibiotics, and metals such as iron or copper. Coloured compounds from such sources are adsorbed into dental pellicles or tooth surfaces, causing stains to appear.

What types of teeth whitening products are available today?

Apart from in-office teeth whitening, there is a broad range of over-the-counter teeth whitening products available that can help lighten teeth by 1 to 2 shades.

Such products are often marketed to target varying teeth discolouration problems. For example, did you know that there are toothpastes marketed specifically for smokers? These products claim to contain larger quantities of abrasives and detergents that reduce stains.

Here’s the lowdown on common teeth whitening products available in Singapore:

Whitening toothpaste
  • These contain more abrasives and detergents than standard toothpaste but do not contain bleach (sodium hypochlorite).
  • They may contain small amounts of carbamide peroxide or hydrogen peroxide, which are teeth lightening agents.
Whitening strips and gels
  • Whitening strips consist of a thin layer of peroxide gel on plastic strips. These are shaped to fit onto the buccal surfaces of the teeth.
  • There are a variety of white strip products on the market with varying instructions (eg. apply twice daily for 30 minutes for two weeks).
  • Effects are usually seen in a few days.
Whitening gels
  • These peroxide-based gels are “painted” directly onto teeth surfaces with a small brush.
  • These gels are usually applied twice daily for two weeks.
Whitening rinses
  • Such rinses contain oxygen sources such as hydrogen peroxide, which react with chromogens.
  • Rinses are usually used twice daily and can take up to 3 months to lighten teeth by 1 to 2 shades.
Tray-based teeth whitening
  • Available both professionally and over-the-counter, this method involves a fitted tray containing carbamide peroxide-whitening gel that is worn for 2 to 4 hours during the day or overnight.
  • Teeth are usually lightened by 1 to 2 shades in a few days.

Achieve White Teeth

Are home teeth whitening kits effective?

While the lure of OTC teeth whitening kits is understandable, what with their accessibility and price, research shows that not all products are effective. Studies have proven that whitening chewing gum, for example, is not any more effective than normal gum[2]. Dental clinics will be able to recommend and offer professional home whitening kits if you are keen.

Moreover, the clinical efficacy of whitening toothpaste remains hotly debated[3] – although whitening toothpaste can prevent superficial extrinsic tooth stains, the whitening effect seems to be insignificant and short-lived. Whitening toothpaste, like conventional toothpaste, cannot prevent teeth discolouration.

Can teeth whitening damage teeth?

The Health Sciences Authority in Singapore strongly warns that home teeth whitening products should not contain more than 0.1% hydrogen peroxide, and that if they do, they can only be supplied by registered dentists.

This is for good reason as well, as improper use of teeth whitening kits can lead to detrimental results such as:

The benefits of in-office teeth whitening

The potential risks of home teeth whitening kits makes seeing a trained professional the better choice. Additionally:

Should I use a home teeth whitening kit or see a dentist?

If a teeth whitening kit is used as per the manufacturer’s instructions, it can prove safe and effective. But the potential risks remain and are best avoided with the help of an expert.

Furthermore, dental procedures should be tailored to the individual and is based upon factors such as:

Fact remains that most patients are not often aware of the risks associated with teeth whitening kits, and may thus be ill-equipped to identify or manage adverse side effects. A professional on the other hand will be able to give advice on and tailor teeth whitening strategies, reduce potential risks, and optimise regimen benefits.

Does this mean you should avoid over-the-counter products entirely? Not necessarily – but they should be used for mild cases of teeth discolouration at best under the guidance of a dentist.

Teeth whitening is not just a skin-deep fix

It is increasingly undeniable that a good dental appearance is a crucial aspect of successful modern life.

Whether your teeth discolouration is mild or severe, it’s never too late to get to the root of your dental problems and polish up your life.

Have questions? Feel free to drop me a message and I’m happy to help!


  1. Nikitin, J., & Freund, A. M. (2019). The Motivational Power of the Happy Face. Brain sciences, 9(1), 6.
  2. Demarco, F. F., Meireles, S. S., & Masotti, A. S. (2009). Over-the-counter whitening agents: a concise review. Brazilian oral research, 23 Suppl 1, 64–70.
  3. Epple, M., Meyer, F., & Enax, J. (2019). A Critical Review of Modern Concepts for Teeth Whitening. Dentistry journal, 7(3), 79.
  4. Li, Y., & Greenwall, L. (2013). Safety issues of tooth whitening using peroxide-based materials. British dental journal, 215(1), 29–34.

Dr. Nicole Ann Lee: Can tooth decay in baby teeth affect permanent teeth?

Picture of a kid holding on to a kid toothbrush

Baby teeth, or milk teeth, are the first set of teeth that children have by the time they reach 3 years old. These will subsequently fall off and be replaced by a second set of permanent teeth at the appropriate age. As a result, many parents often think that baby teeth aren’t important because they will be replaced anyway, and so there is no need to start dental care early. This is a huge misconception — let me explain why. 

What is the importance of baby teeth? 

Baby teeth, though temporary to some extent, play an important role in the transition into adult teeth, speech and function. The presence of baby teeth determines the amount of available space that the succedaneous permanent teeth may take up. This means that they hold the space until the adult teeth are ready to erupt and thereby help guide the latter into position, making sure they stay straight and even for a beautiful next set of teeth. 

If your child, unfortunately, loses his/her front teeth prematurely, it could potentially have some impact on their speech as they might be unable to enunciate or articulate clearly at the early stages of learning.

Several studies have shown that children who establish good oral hygiene habits early on in life are more likely to carry these positive habits into adulthood. This enables them to prevent dental problems throughout life, maintain healthy self-esteem and even have better performance at school. 

Simply put, baby teeth pave the way for permanent teeth - so don’t let them decay! 

What happens if you don’t fix cavities in baby teeth? 

Teeth are damaged by the presence of dental plaque which contains harmful decay-causing bacteria. Tooth decay can lead to cavities (dental caries) when enamel, the outermost layer of the teeth, starts to break down, leaving behind holes in the teeth. Decayed teeth are often roughened, blackened and unsightly, which may impact your child’s appearance and make them less confident. 

Aesthetics aside, cavities in baby teeth can result in the following problems: 

Oral health problems

Untreated cavities have the potential to lead to infection, resulting in significant pain and even emotional distress. Often, I find that this negatively impacts the child’s eating and sleeping habits as well as overall health; studies have also shown the link between childhood cavities, malnutrition and eating disorders. 

If you find your little one acting out more than usual or refusing to eat, it is possible he/she could be experiencing pain from tooth decay. 

Damage to permanent teeth

What starts out as an infection may progress into an abscess, a pus-filled “pimple”-like bubble, which can be very painful. On top of that, it may interfere with or worse still stop the development of the permanent tooth below, delay its eruption or even prevent it from erupting at all. Other possible problems that the succeeding permanent teeth may encounter are permanent discolouration and/or malformations. 

Orthodontic problems

If there is early loss of a baby tooth, orthodontic issues may arise. Neighbouring teeth may shift to fill the empty space, which could then pose a problem when it is time for the adult teeth to grow out. The permanent teeth in that area may be misaligned and/or crowded out if the space at the resulting area is insufficient, which can further cause the other teeth to become crooked too. In order to correct the alignment and bite of the permanent teeth, more costly treatments such as braces or Invisalign may be needed. 

Picture of a kid holding on to a tooth that fell off due to tooth decay

How do I look out for tooth decay in baby teeth? 

Common signs and symptoms of tooth decay in baby teeth include: 

  • Dark or brown spots on teeth
  • Holes in teeth, possibly with food debris stuck within
  • Pain pertaining to the teeth 
  • Swelling around the teeth
  • “Pimple”-like an abscess on the gum above the teeth
  • Bad breath

If you notice any of these signs and symptoms, or if your child is suddenly having problems eating and/or sleeping, visit a paediatric dentist straight away! 

How do I keep baby teeth healthy?

Make sure your child brushes his/her teeth well twice a day. I recommend using fluoridated toothpaste, but using the right fluoride toothpaste and the right amounts of it is crucial! Our previous article on whether fluoride toothpaste is safe for children can tell you more. 

Next, avoid consuming too many sweets and bring them to the dentist regularly for check-ups and routine cleaning. It is a common misconception that we should only see the dentist if there’s a problem, but we prefer to avoid doing this so we do not scare the little ones at each dental visit. I recommend regular dental visits from the age of 1 or when primary teeth start to erupt. 

Generally speaking, as long as your child maintains good oral hygiene and goes for scheduled dental visits, their baby teeth should be just fine!

Do you have a question for me regarding paediatric dentistry? Feel free to ask away, I am more than happy to answer them! 


  1. Mark, A. M. (2020). Helping your child fight tooth decay. The Journal of the American Dental Association, 151(2), 154.
  2. Zou, J., Meng, M., Law, C. S., Rao, Y., & Zhou, X. (2018). Common dental diseases in children and malocclusion. International journal of oral science, 10(1), 1-7.

Dr. Nicole Ann Lee: Should my child use fluoridated toothpaste?

Little girl using toothbrush

Seeing your little ones grow their first set of teeth is for sure exciting. When it comes to dental care, experts agree that starting as soon as possible is important for developing proper oral hygiene habits, and certainly key to ensuring a beautiful smile down the road. 

I am sure the use of fluoridated toothpaste is a common concern amongst parents.

Is fluoride toothpaste safe for children? 

One of the most frequently asked questions I get from parents is whether the use of fluoridated toothpaste is suitable for their child.

The American Academy of Paediatrics recommends that as soon as a child’s teeth start to come in, brushing for him/her should already be done so with fluoridated toothpaste. 

Fluoride helps prevent the formation of cavities and is even able to reverse early tooth decay! 

However, more is not always better! You’ll want to be careful about using too much toothpaste to guard against dental fluorosis, a condition which occurs when too much fluoride is ingested at a young age during the development of teeth, causing permanent opaque white or brown discolouration.

So how much fluoride toothpaste should children use? 

As a general rule of thumb, it is recommended that:

  • Children aged 2-3: Grain-sized smear 
  • Children aged 3 and older: Pea-sized blob 

Personally, besides using age as an estimated timeline, I may sometimes make individualized recommendations for each child depending on his/her ability to spit. Additionally, I would also assess the overall decay risk of each child and take into consideration the risk-benefit ratio before advising accordingly.

It’s important to keep to these guidelines as well as the advice of your child’s dentist, because you want sufficient fluoride exposure to protect your child’s teeth from decay, yet not too much to prevent the occurrence of pitting and discolouration. 

Do not hesitate to convey your difficulties to your child’s dentist, we usually have some tips and tricks up our sleeves to help you along!

Little boy using a toothbrush with Fluoridated Toothpaste

Apart from using a small amount of toothpaste, here are some other important points for introducing fluoridated toothpaste to your little one: 

Choose a toothpaste that is age-appropriate 

Keep a lookout for labels on the boxes. Use a toothpaste that contains at least 1000ppm of fluoride and brush twice a day for about 2 minutes. 

Choose the right flavour 

You might be used to brushing with minty-fresh toothpaste, but most young children do not enjoy such strong “spicy” flavours. Instead, choose one that your child is able to tolerate; I usually recommend starting with fruits that they already enjoy. I’m sure your child’s dentist can recommend some that is right for him/her.

Keep the toothpaste out of reach 

Children are filled with curiosity and may put anything and everything in their mouths. Near the top of that list is toothpaste, especially when it tastes good. Apart from supervising your child when he/she brushes his/her teeth, I definitely recommend you being the one to dispense the toothpaste and otherwise keeping the tubes out of reach to prevent ‘snacking’. 

Is it okay if my child does not use fluoride toothpaste?

I usually only recommend this if your child is absolutely cavity-free and with good habits.

If you are really concerned about your child using fluoridated toothpaste, it is possible to opt for fluoride-free toothpaste. However, you need to bear in mind that while brushing with fluoride-free toothpaste can still clean teeth, it does not protect against tooth decay. 

It is crucial to make sure your child brushes well and goes for regular dental check-ups and cleaning to catch early signs of decay, and your paediatric dentist may advise as required.

What should I do then?

Finally, I recommend young children see a paediatric dentist early. Not only can we determine the urgency if your child needs fluoridated toothpaste (or if at all), we can also detect possible dental defects early and advise appropriately. 

My position also gives me the opportunity to guide parents on the steps to take to allow their children to grow up with beautiful healthy teeth. It is my pleasure to ensure your child is given optimal oral care, both at the clinic and at home!

Ask away if you have more questions for me regarding paediatric dentistry, I am more than happy to answer them! 


  1. Chen, A. Y., Wright, J. T., Quiñonez, R. B., & Phillips, C. (2018). Appropriate Fluoride Toothpaste Application: Improving Caregiver Compliance. Pediatric dentistry, 40(7), 412–418.
  2. Wright, J. T., Hanson, N., Ristic, H., Whall, C. W., Estrich, C. G., & Zentz, R. R. (2014). Fluoride toothpaste efficacy and safety in children younger than 6 years: a systematic review. Journal of the American Dental Association (1939), 145(2), 182–189.

Dr. Nicole Ann Lee: When should I bring my child to the dentist?

Dr Nicole Ann performing surgery in AnDental Clinic (child's first dentist visit)

Parents often ask whether it’s necessary for their child to go for regular dental treatments — the answer is yes! We advise that the very first dental visit of children to be done by the time they turn 1-year-old! Starting early is important for cultivating good dental habits to aid in the prevention of cavities and other related dental problems.

This is also advocated by the American Academy of Paediatric Dentistry, in that the first dental visit of every child is to be within 6 months from when the first tooth erupts and no later than the age of 1, more so when primary teeth erupt¹. 

During this introductory visit, we want to find out more about your child and his/her daily habits. Following the consultation is a dental examination, in which routine dental instruments and/or equipment might be introduced in an age-appropriate fashion. This helps give us a better idea on anything we may be able to pre-empt and to advise on further preventive care tailored specially for him/her. 

Dr Nicole giving a high 5 to a kid

Why do children have a need for paediatric dentistry? 

It is a common misconception that we should only visit the dentist when a problem (e.g. pain, infection, swelling, a bad fall) arises. However, this potentially leads to a less pleasant first visit for the child as there is a possibility of the need for more invasive treatment or a procedure of some sort when that happens. Ideally, we would very much prefer that the child is accustomed by the regular visits and comfortable in the dental environment before gradually easing them into readily accepting more complex procedures.

During your child’s dental appointment, we want them to feel that they are in a safe environment, so you will find that we usually steer away from adult terminology. Instead, we tend to use fun descriptive words that are easy to understand in order to engage your child so that these new experiences may be more well-accepted by them. Therefore, even at home, please try not to use words such as “scary”, “injection”, “drill”. 

How can I prepare my child for his/her first dental visit?

It may be useful to bring along your child’s regular toothbrush and toothpaste for the dental visit so that we can practice brushing with items that already belongs to him/her. Parents may practice brushing or checking their child’s teeth while the child is lying down on mom or dad’s lap, and this can even be done on the sofa or on the bed.

Dr Nicole making a pinky promise with a little girl

We especially love it when parents are eagerly involved in their child’s dental care! We want to help you ensure your children grow up healthy and with a beautiful smile, and are always pleased to answer any questions you may have on your child’s teeth and dental care habits — so do not be shy to ask during the visit. 

If you haven’t already done so, it is certainly not too late to bring your little one in for a fun-filled first dental visit!

How should my child be brushing his/her teeth? What toothbrush and toothpaste should we be using?

Parents should pick a small-sized soft-bristled toothbrush for your children’s baby teeth.

Ideally, parent(s) should be brushing for their child twice a day, everyday. At the bare minimum, an adult should be assisting the brushing of a child’s teeth every night. 

Most children under the age of 6 do not have sufficient dexterity to perform a good oral hygiene routine on their own.

Dr Nicole teaching little boy how to clean his teeth

Most young children do not like the strong mint taste that is commonly found in adult toothpaste. There are many brands in the market offering a variety of fruity flavours for children’s toothpastes. You may select any flavour that your child is comfortable and most importantly, willing to brush with. 

As parents, we always want what is best for our children. In this case, however, organic toothpaste may not always be the best option. This is because fluoride (which is typically lacking in the majority of organic toothpastes) helps prevent dental cavities and reverse early tooth decay lesions². 

Therefore, fluoridated toothpaste of appropriate concentrations should be introduced into your child’s oral hygiene routine as early as when the first few teeth erupt, in controlled amounts3. This is especially the case if your child is assessed to be of high dental decay risk and requires more intense protection, as advised by his/her paediatric dentist. Parents should be the ones dispensing the right amount of toothpaste for their children. As a general rule, simple smear of adequately fluoridated toothpaste should be used up to age 3, after which a pea-sized amount of fluoridated toothpaste used from 3- to 6-years-old or once your child is able to spit4,5. 

Of course, each precious little one is unique in his/her own way. 

Do not hesitate to speak to your paediatric dentist and find out what works specifically for your child!


  2. Marinho, V. C., Higgins, J. P., Sheiham, A., & Logan, S. (2003). Fluoride toothpastes for preventing dental caries in children and adolescents. The Cochrane database of systematic reviews, (1), CD002278.
  3. Walsh, T., Worthington, H. V., Glenny, A. M., Marinho, V. C., & Jeroncic, A. (2019). Fluoride toothpastes of different concentrations for preventing dental caries. The Cochrane database of systematic reviews, 3(3), CD007868.

Am I in a high risk group for dental implant failure?

Advancements in medical technology have helped dental implant surgery become safe, effective and replicable; suitable for many patient profiles. Implants are now a very popular and mainstream dental procedure, being a form of teeth replacement that enables the surgeon to restore both the aesthetics as well as the function of a tooth. The 10-year success rate of a dental implant hovers around 97% for some implant brands.

However, dental implant surgery does come with some risks. Some of my patients are considered to be ideal candidates for dental implant surgery; they are healthy individuals who have a combination of good gum and bone health with no pre-existing medical or dental conditions. However, other patients who do not have such a clean bill of health might find that opting for dental implant surgery might expose them to some potentially hazardous medical situations.

dental implant illustration

Firstly, what can cause dental implant failure?

Before discussing whether or not a patient belongs in a high-risk group, we should first understand why dental implants fail in the first place.

So what are some of the most common reasons for dental implant failure?

While some of these reasons for failure are linked to external factors (such as excessive bite force), the main reasons for implant failure are usually related to patients who are in the high-risk group due to health, medication or other lifestyle factors. Only a proper and thorough consultation with your dental surgeon can adequately determine whether or not you are a good candidate for a dental implant.

So, what are some patient-related factors that could cause a patient to be at high risk of dental implant failure?

Having pre-existing medical conditions

Before you even consider getting dental implants, it is important for your periodontist or dental surgeon to understand your current bill of health. If you have pre-existing medical conditions like diabetes, rheumatoid arthritis or other forms of autoimmune diseases, you may not be a suitable candidate for implants. These conditions reduce the body’s natural ability to heal, which is imperative in helping the dental implant fuse well to your bone.

Having pre-existing dental conditions like gum disease

Please do not get your implants placed if you have active gum disease. Having an untreated periodontal condition can increase your risk of infection as well as presenting you with an increased risk of dental implant failure. One of the primary causes of gum disease is bacteria. When bacteria is still present in the pockets of unhealthy gums, they can track to the newly placed dental implants and cause an infection of the implants.

That being said, dental implant treatment will still be successful for those patients who have undergone gum treatment and are motivated to keep their teeth very clean. It's just as important to see your dentist regularly even after your gums are treated to make sure the gum disease does not recur dues to inadequate brushing!

Current medication

The use of certain types of medications can also contribute to dental implant complications. It’s very important to be honest and thorough with your dental surgeon about what medications you’re currently taking so that the surgeon can give you the green light to continue taking them safely. Certain anti-depressant and heartburn medications have been found by studies to reduce bone growth, which can impair the body’s ability to fuse the implant successfully into the jaw bone (1). Other medications used for the treatment of osteoporosis may also reduce blood supply to the jaw bone and affect the implant success rate.

Having insufficient or unhealthy jaw bone

The jaw bone is an important foundation in supporting dental implants. Without sufficient or healthy jaw bone, the dental surgeon won’t be able to insert and anchor the implant. The implant also runs an increased risk of becoming dislodged or knocked out of place when eating if the jaw bone is not inherently strong and stable.

This means that for patients that are suffering from degenerative bone diseases like severe osteoporosis, dental implants may not be a viable solution for them. Patients with osteoporosis suffer from a lack of bone density, which means their fragile bones run an increased risk of becoming fractured or damaged during or after the surgery. Point to note though: new and improved implant surfaces have reached a point where it is still possible to place implants in patients with osteopenia (the stage just before osteoporosis) or mild osteoporosis. You just need to inform your dental surgeon of your condition and we can make a decision on the likelihood of implant success based on the severity of the osteoporotic condition.

There are other oral diseases that might cause bone deterioration in one’s mouth, so it is important that there are no conditions left untreated before embarking on dental implant surgery.

Will Smoking cause dental implant failure?

Smoking is a lifestyle choice that has clear negative effects on your dental health. The literature surrounding smoking and dental health suggests that smoking causes a higher rate of plaque accumulation and an increased chance of gingivitis or periodontitis(2)

On top of that, smoking exposes your gums and teeth to heat as well as certain additives like nicotine, carbon monoxide and hydrogen cyanide, which will impair the body’s ability to heal while also leaving the gums more susceptible to complications and implant failure. In order to give your implant the best chances of not being rejected, you are usually advised to stop smoking cigarettes at least 7 days prior to your surgery as well for up to 2 months post-dental implant surgery (3).

woman smoking cigarette with yellow teeth

Overall, for patients who are going for their first dental implant surgery, thinking of the risks involved can sometimes be stressful due to the fact that it is “surgical” in nature. However, it is important to remember that dental implant surgery is a safe and well-established procedure and the success for many patients who undergo it is generally very high. It is important to choose a dental surgeon who works closely with you to ensure you remain calm and reassured throughout every step of the way of your dental implant journey.


    What to Know About Dental Implant Complications and Failure
    Levin, Liran DMD*; Schwartz-Arad, Devorah DMD, PhD. The Effect of Cigarette Smoking on Dental Implants and Related Surgery. Implant Dentistry: December 2005 - Volume 14 - Issue 4 - p 357-363
    V. Kasat and R. Ladda1. Smoking and dental implants. J Int Soc Prev Community Dent. 2012 Jul-Dec; 2(2): 38–41.

What potential complications do I face when getting a dental implant?

In 2020, tooth replacement procedures have become incredibly commonplace.  Dental implants, in particular, have become a very popular and sought after procedure. Other tooth replacement strategies like dentures and bridges have generally become less favoured. Dental implants feel almost like your own tooth and stay in your mouth while dentures need to be removed before you sleep. Dental bridges involve cutting down adjacent teeth to hold the “fake tooth” and can damage the nerves in the adjacent teeth. A dental implant on the other hand exists as an independent unit. Done successfully, dental implants can remain in good condition in a patient’s mouth for up to 20 to 25 years! 

Dental implants are permanent tooth replacements which are designed to fuse with your jaw bone in a process known as osseointegration. They are meant to serve as both an aesthetic and mechanical replacement to your teeth and are meant to be comfortable, convenient and long lasting.

However, in a low percentage of cases, there are some situations where complications might arise during or after the dental implant procedure is completed. While these complications are rare (and experienced dental surgeons are very adept at avoiding such situations from occurring), it is important for both patients and dental surgeons alike to understand and recognize them so that the necessary precautions can be taken beforehand to avoid them.

woman holding dental implant illustration piece

Intraoperative complications

These are complications that primarily happen during the actual operation itself. These are considerably rare and can be largely avoided through proper pre-operative planning as well as precise execution while performing a dental implant procedure.

Blood vessel and nerve damage

Blood vessel and nerve damage can occur during the actual dental implant procedure itself and thus the dental surgeon will need to examine you and take an Xray or use a digital computer topographical technology to elucidate the blood vessels and nerves before we schedule you for surgery. Nowadays we are also able to fabricate computer guided surgical stents to further enhance the safety of the surgery.

If nerves are injured during surgery, the patient will likely suffer a degree of neuropathic pain which can greatly affect their sleep and their quality of life. Injury to this nerve can also cause numbness to the jaw. The nerve most usually compromised in this case is the inferior alveolar nerve, and is responsible for our sensitivity to external stimuli like temperature and pressure. Unlike damage to skin and tissue which generally heal over time, nerve damage can be difficult to reverse (2). Damage to blood vessels during the procedure may cause excessive bleeding during the surgery.

By using x-rays and other digital computer topographical technology, experienced dental surgeons are largely able to avoid causing any form of intraoperative complications to the patient embarking on dental implant procedures.

Lack of stability of the implant fixture during placement

In order to insert the implant, sufficient bone volume and density is required in order to keep the implant strong and stable. 

For patients who do not have sufficient bone volume to sustain an implant safely, bone is grafted from a donor site or other sterilized bone graft materials prior to the dental implant surgery. When the bone has solidified, the implant fixture can then be successfully embedded in the new bone.

If there is insufficient mineralisation of bone, especially in patients with soft bone conditions like Osteopenia or Osteoporosis, there might be difficulty engaging the implant fixture in the soft bone and the implant might not be stable. In this case, we will have to stop the surgery, allow the bone to grow back hopefully stronger and attempt the implant surgery at a later date.

Post-operative complications

Even after the completion of a successful dental implant surgery, aftercare and good oral hygiene habits are imperative for the dental implant to remain stable and healthy for a long period of time. Always consult thoroughly with your surgeon and follow any aftercare procedures closely to give yourself the best chance of making your dental implant surgery a success.

Chance of Infection

As dental implants are surgical in nature, there is always going to be a risk of infection. The chances of infection occurring is also a lot higher if you are a smoker or if you don’t practise proper dental hygiene after the procedure.

The infection of the treatment site can sometimes occur as an abscess near the site due to the accumulation of bacteria. Hence, some dental surgeons will prescribe their patients with a course of antibiotics after surgery to avoid this from happening. Although studies show that prophylactic antibiotics for each implant surgery is not mandatory, Antibiotics are still useful in preventing postoperative infections after implant placement. (1)

Infection is particularly dangerous as it could spread to other parts of the body, causing a fever and affecting other bodily functions. It is extremely important that patients follow their surgeon’s instructions for aftercare in order to avoid this from happening. Treatment for infections will depend on how severe the infection is and where the infection is located.

Breakage of the implant due to long term excessive force

This is a common complication that should not be overlooked. Much like how sometimes teeth can be chipped due to accidents while playing sports, any form of excessive impact can possibly damage the dental implant crown, screw or even injure the bone underneath, leading to instability.

For some patients who have bruxism (teeth grinding during sleep), they could be damaging their dental implant nightly without being fully aware of it. If you suffer from bruxism, you should consider wearing a mouth guard or mouth shield at night in order to prevent your dental implant from sustaining any long term damage.

Potential Dental Implant Complications

Although dental implant procedures do present with risks, it is important to remember that most dental implant procedures will be successful. Should there be an unlikely event where the dental implant fails, you will likely need to have the implant removed and the bone around the treatment area cleaned up. After 4 to 6 months of healing, you will be allowed to opt for the procedure once more should you so choose.


    Hemchand Surapaneni, Pallavi Samatha Yalamanchili, Md. Hafeez Basha, Sushma Potluri, Nirupa Elisetti, and M. V. Kiran Kumar. Antibiotics in dental implants: A review of literature. J Pharm Bioallied Sci. 2016 Oct; 8(Suppl 1): S28–S31.
    Ken-ichi Fukuda, Tatsuya Ichinohe, and Yuzuru Kaneko. Pain Management for Nerve Injury following Dental Implant Surgery at Tokyo Dental College Hospital. Int J Dent. 2012; 2012: 209474.

Wanna get a dental implant? Here’s what you should know beforehand.

What is a dental implant?

Dental implants are artificial replacements for teeth that may have been lost due to large cavities, a fall, or gum disease.
Essentially, these dental implant(s) are designed to look exactly like the rest of your teeth (like a bionic tooth ?).

This may sound simple to achieve, but it really isn’t! Implant dentistry is a highly specialized field of dentistry and it takes a lot of skill, knowledge and planning in order to ensure that the implant fits seamlessly into your mouth. 

Essentially, a dental implant is made out of 3 things:

dental implant illustration

Screw (Fixture)

Made out of titanium alloy, this part of the implant goes directly into your jawbone and essentially replaces the missing tooth root. Once placed into your bone, it needs to fuse to your bone in a process called osseointegration.

Connector (Abutment)

This metal bit locks into the screw and connects to the implant crown; thus supporting the crown and making sure that the implant crown is locked in tightly with the screw.

Implant crown

The part of the implant that is designed to look like your natural teeth is called the crown. Generally, crowns are made out of porcelain fused to metal, although there are zirconia alternatives as well. Of course, they are made in a colour that should match the rest of your teeth perfectly.

What are some of the benefits of having dental implants?

Maintain facial structure

In the unfortunate event that you lose some teeth, the bone that surrounds the tooth root starts to resorb and melt away. If this is not addressed properly with a dental implant, you might risk your jaw bone eventually shrinking and the facial features might appear “collapsed”.

The other problem is that the adjacent remaining teeth can start to tilt into the missing tooth space. Both jaws are now less supported, and this can lead to loss of lower facial height. Your facial features can start changing!

With the support of dental implants, you’ll be able to retain the structural integrity of your jawbone as well as keep a nice and young-looking smile! 🙂

Preserve your surrounding teeth

In the past before implant dentistry was really developed, dentists would use bridges in order to replace missing teeth. That would sometimes require the cutting of the adjacent teeth to support the missing tooth or teeth. With a dental implant, the surrounding teeth do not need to be cut and remain as an independent unit.

The other option is to wear a denture but partial dentures would need to be hooked to the adjacent teeth. Sometimes this increased load on the teeth can caused them to be rocked out faster.? So a dental implant prevents the adjacent teeth from eventually loosening from the pressure and falling off more quickly than they would have.

Maintain a beautiful, natural-looking smile

More than its structural importance to your oral health, dental implants were also created to look and feel precisely like your natural teeth – all the while preserving the bone and gum tissue around it. It’s really important that your dentist does a treatment plan with precision to make your dental implant fit in impeccably. So no one knows it’s not a real tooth!

They can last a long time

Dental implants are made out of medical-grade titanium, and some brands include zirconium mixed with titanium which males the dental implant extremely hardy. These materials cannot corrode and decay with time. Essentially, an implant done correctly has a survival rate of 96.4% after 10 years (as this large scale scientific paper shows).

Dental Implant Procedure

Am I a good candidate for dental implants?

Implant dentistry has progressed to the point that almost anyone can get a dental implant – with a a few caveats. During your consultation, factors that will be looked at include:

  1. The density and quality of the bone you have at the implant site
  2. How many implants you require and whether your bone structure support it
  3. Whether or not you will require other procedures to be done beforehand to prepare you for implants

Using a CT scan, we are now able to take a precise scan of your jaw bone which shows us the volume, shape and existing quality of your jaw bone.

Depending on what we find in the scan, sometimes a bone graft is also needed if you do not have enough bone around the target implant area.

There are also some groups of patients that may have systemic factors working against them when it comes to getting implants.

Gum Disease

In order to prevent your implant from failing, it is imperative that you have good gum health. If you are suffering from a gum-related disease like gingivitis or periodontitis, this could mean that the infection might spread to the implant and cause it to fail. It is important that all gum related diseases are fully treated before an implant is even considered.


Habitual smokers do not make good candidates for dental implants as cigarette smoke can affect the blood flow to the gums, which drastically slows down the gum’s ability to heal itself post-surgery. Smoking also caused suppressed the immune system. A good immune system is essential for post-surgical healing! Many studies have shown that smokers have a 10% to 20% increase in the chance of implant failure as compared to non-smokers!

All is not lost though – the number of cigarettes smoked is directly proportional to the chance of failure. So if you can reduce the number of cigarettes smoked or refrain from smoking pre and post surgery…. that will decrease the chance of implant failure!

Weak or poor quality bone

This generally affects elderly patients –conditions like osteoporosis may cause a drop in bone volume and density and this inadvertently affects the jaw bone. Also, older patients tend to have more fragile and brittle bones, which have a higher risk of fracturing during surgery. This has to be considered in the pre-implant placement process and discussed with you.

Pre-existing medical conditions & medication

If you have a condition that jeopardizes your body’s ability to heal, then the risk of implant failure becomes much higher. Such conditions include autoimmune diseases, diabetes and long term steroid use. I always ensure that my patients disclose their full medical history to me, (long medical history checklist alert) including what medicine they are currently taking before I decide whether or not they are suitable for dental implant surgery.

There are a large number of factors that go into determining whether or not implants are suitable for you; if you are interested in getting a dental implant, visit a periodontist, oral surgeon or dentist for a consultation before making that decision!