I was recently forwarded a link to this article and asked my opinion on the subject, and decided to post my response here, and carry on the discussion afterwards on facebook.
The article is title: “The influence of the maxillary frenum on the development and pattern of dental caries on anterior teeth in breastfeeding infants: Prevention, Diagnosis, and Treatment”, and the article can be found by clicking this link.
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Is the Frenum the Cause of Decay?
The article references infants developing decay on the outer surface of their upper front teeth. The infants most susceptible had increased frenum attachments and were nursing at-will, with multiple feedings throughout the night, and to older ages of 2 or 3.
From the observation based study (which is considered a very low level of evidence, and used for guiding more comprehensive studies), the conclusions and recommendations are based more around the frenectomy, rather than the other possible causes. The frenectomy may have an impact on how the tongue can move across the front teeth, but that is only one factor that is presented here.
The more controllable factors relate to feeding habits, overall nutrition, and oral hygiene habits.
1. Feeding habits:
With having my own children, my wife and I did a fair bit of research into how we wanted to raise our children, particularly with feeding habits, nursing vs bottle, etc. The path we chose was to nurse, and set a schedule, which we adapted as needed for growth spurts. There is a lot of research out there to support this approach, and I recognize others will have different views on this.
Relative to this article, one of the concerns I have with the feeding habits presented, is the at-will feeding throughout the night. Most children by 6 months (before teeth come in) are able to go through the night without any feeding, and be perfectly healthy. The infants shown in the article are all over one year of age, with most being around 2 years of age. When introducing night time feedings (feed then infant goes right back to sleep), there is not a great opportunity for the tongue and saliva to really clear away any food remnants. This allows the milk to stay in the mouth as a food source for cavity causing bacteria. Prior to teeth coming into the mouth, not a problem, but once the teeth are in, this type of routine can significantly contribute to cavity development if precautions are not taken.
2. Overall Nutrition
A big shocker for me while reading this article was the strictly nursing diet of children up to and over 3 years of age. I know many people who continue to nurse their children to around this age, but this was the first I have heard of this being the exclusive source of nourishment for a 3 year old child. This has me wondering if some of the cause of decay was due to an overall lack of nourishment due to not introducing other food sources to help meet the body’s demand to keep up with growth and increased physical activity. I do not have any specific research on this to reference, but definitely something I would look into if I was considering raising a child to age 3+ solely on breast milk.
3. Oral Hygiene
The article references the difficulty the frenum poses on the tongue’s ability to clean the front teeth. This could easily be overcome by the assistance of a good oral hygiene routine. After feeding, taking a damp cloth and wiping the front teeth would remove the mild residue and reduce the food source for cavity causing bacteria. This often happens more for children with daytime feeding, and when solid foods are introduced. However, night time feedings are often accompanied by a feed, and go directly back to sleep routine (maybe a diaper change in there too if needed). Mom’s are often too tired, and usually not well informed, and so the child goes back to sleep without the teeth being cleaned.
Based on the above, and my personal experiences with my own children, who are cavity free and have had class 3/4 frenum attachments, I would not recommend a frenectomy on an infant. My focus would primarily be on dietary and oral hygiene habits. These can compensate readily for the frenum attachment and allow the body to do what it was meant to do naturally.
Final note, ethnicity should also be considered. It is very common for some ethnic groups to have diastemas and class 4 frenum attachments in adulthood due to the genetic nature of their jaw development, and be perfectly healthy and cavity free. Therefore, consider all the factors prior to having a frenectomy done on your child.
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Is a Frenectomy the Best Solution?
The suggested solution referenced in the article is a frenectomy with a laser. Although there can be potential benefits to doing a frenectomy, and a laser being a great choice for performing the procedure, is it really the best solution in all cases? I would propose it is not from a few aspects.
1. Resolution on its own:
The article provides 4 classifications for frenum attachments and states there are no studies to show class 3 or 4 frenum attachments will change to being a class 1 or 2 attachment over time. I have not seen any studies on this, but have seen this occur in many cases. In school I was taught not to do frenectomies on children until after orthodontic treatment has been completed, usually in the teen years. Based on these teachings, I have left these untouched through early childhood. I know personally infants who have had Class 3 and 4 frenum attachments that have receded as the baby teeth come in, and further recede as the adult teeth come in. My own two children are perfect examples of this as my son had a class 3 attachment, and my daughter had a class 4 attachment. Both of these have receded with development. Part of this is due to increased downward growth of the bone structure for the teeth, as well as the teeth pushing towards each other to fit in the mouth, pushing back the frenum tissue. If you look at the pictures in the article of the 4 different classes, you will note the class 4 case is just starting to get the teeth in, whereas the photos of class 1 and class 2 have all the baby teeth in. It should also be noted in the case of the class I photo, there is insufficient spacing between the teeth to make room for the adult teeth and that child will likely require orthodontic treatment in the future. Some spacing between the front baby teeth is a good thing.
So, if many cases will resolve on their own, should it really be treated?
2. Risks of the frenectomy:
With doing some internet research, there is debate over whether a frenectomy will cause scar tissue and prevent the movement of teeth to close up a space between the front teeth (a diastema). What I was taught, and from general consensus online, a frenectomy can result in scar tissue buildup that can prevent the front teeth from moving together. There is the possibility that the space can be closed if orthodontic treatment is initiated immediately after the frenectomy, but there is debate on the long term stability of this approach.
In relation to the article, I would question the long term impact on anterior spacing and diastema formation as a result of early childhood frenectomies. Although this would not likely result in any kind of drastic functional issue in the future, it has potential for significant cosmetic issues, which would have me question, is there a better option?