ORAL MANAGEMENT A STUDY GUIDE OF PEDIATRIC PATIENTS FOR NON-DENTAL PROFESSIONALS

Transcription

1 ORAL MANAGEMENT OF PEDIATRIC PATIENTS FOR NON-DENTAL PROFESSIONALS A STUDY GUIDE The Center for Leadership in Pediatric Dentistry The University of Iowa Department of Pediatric Dentistry College of Dentistry Iowa City, IA Supported by Grant # 6T17 MC S1 RO From the Maternal and Child Health Bureau, HRSA, DHHS

2 ORAL MANAGEMENT OF PEDIATRIC PATIENTS FOR NON-DENTAL PROFESSIONALS A STUDY GUIDE Arthur J. Nowak, D.M.D. Departments of Pediatric Dentistry and Pediatrics Colleges of Dentistry and Medicine Center for Leadership in Pediatric Dentistry The University of Iowa arthur-nowak@uiowa.edu August

3 SUGGESTED CITATION: Nowak AJ. Oral Management of Pediatric Patients for Non-Dental Professionals The Center for Leadership in Pediatric Dentistry, University of Iowa, Iowa City, Iowa; 3

4 TABLE OF CONTENTS Introduction...5 Audience and Purpose...6 How to Use the Guide...7 I - Oral Health and General Health...8 II - Oral Disease...16 III - Common Pediatric Oral Pathology...25 IV - Infant and Toddler Oral Health Management...43 V - VI - VII - Preventive Strategy...50 Nutritive and Non-nutritive Sucking...64 Oral Injuries...70 VIII - Children with Special Health Care Needs...78 IX - Additional Topics...86 Appendix

5 INTRODUCTION Oral health can no longer be considered a separate health issue from general health. The two are one. The mouth is the portal of health. All foods, solid and liquid, and some of the air we need all pass through the mouth. Communication mechanisms are all located in and around the mouth. Initial digestion begins with the availability of oral fluids. The chemistry of taste and smell are initiated by the thousands of taste buds located on the tongue. In addition to the necessity to support life, a person s attractiveness is greatly enhanced by a broad smile with healthy teeth. Signs of illness or disease can be diagnostic in the oral cavity. Vitamin deficiencies, bacterial, viral, and fungal infections, congenital and hereditary conditions can have orofacial manifestations. In addition oral infections can have an impact on health and development as reported in the connection between periodontal disease and preterm/low birth weight infants and cardiac diseases. Severe early childhood caries in infants can lead to inappropriate dietary habits resulting in delayed growth. Medical interventions can directly or indirectly affect oral health outcomes. For example, chemo and radiation therapies can have devastating effects on oral tissues that not only increases the risk of opportunistic infections but also the quality of life. Both traditional and contemporary wonder drugs can affect oral health. Saliva quality and quantity can be side effects of antianxiety, anticonvulsants, antidepressant, antihistamine, decongestants, diuretics, narcotics, nonsteroidal anti-inflammatory drugs and sedatives. Oral preparations like iron supplements can cause extrinsic staining of teeth while tetracyclines can contribute to intrinsic staining of developing dentitions. Dentistry has too frequently provided oral health and disease intervention in isolation from other health professionals. Although many Americans enjoy a healthy functional and esthetically pleasing oral cavity there exists a noticeable disparity in oral health and oral health care among United States populations. To be poor, of color, live in inner cities or 5

6 rural America, on Medicare or Medicaid all place an individual at increased risk for oral disease and more unlikely to find professional intervention. Dentists are relatively few in number and unevenly distributed. Although preventive practices have had remarkable success, the demand for care is great and increases annually. Early intervention remains elusive for many children. Interventions ideally should begin before the oral infection affects the teeth and oral soft tissues. Oral health principles must be understood by all health providers, but particularly by pediatricians and family practitioners. Current pediatric preventive practice guidelines suggest scheduling infant and toddlers on a timed sequence. Physicians and other health providers have nine scheduled preventive interventions from birth to two years of age (Recommendations for Preventive Pediatric Health Care, American Academy of Pediatrics, 1999). This period of life coincides with a period of oral development that is paramount in establishing oral preventive recommendations and a Dental Home. More and more allied health professionals are called upon to interact with infants and toddlers and their parents. These paraprofessionals must also be aware of the principles of oral health. They too must join with dentistry to support early preventive intervention and see that parents and children are not only knowledgeable but responsive to daily preventive practices. AUDIENCE AND PURPOSE Information is paramount to success. Little information on oral health is provided in the formal training of non-dental health professionals. Therefore it is the purpose of this program to provide information on a variety of topics focusing on oral health for the infant, preschool, and young school aged child. Once of school age the majority of children are followed on some scheduled basis by a pediatric dentist or the family s dentist. Therefore non-dental health care professionals can refer questions pertaining to oral health or intervention to them. Although early oral professional intervention is recommended by all health organizations, the age varies from 12 months to three years. Therefore it may be common in some 6

7 communities for the child s primary medical provider and/or allied health care provider to provide guidance and support on oral health issues and concerns of the caregiver before the child has had a first appointment with the dental professional. This program is made up of nine individual topic areas. The goal is to provide the health care provider with sufficient information to address the topic, references to contemporary literature and additional information both written or in the electronic version via www sites. Although comprehensive, the information is not complete. The intent is that non-dental health professionals will have sufficient information to address the common oral health questions of caregivers and be able to direct them to additional resources if needed. In addition, we hope that communication with your dental colleagues will be enhanced and together you can provide coordinated, contemporary and comprehensive health care that now includes the mouth and teeth along with all other organ systems. USING THE STUDY GUIDE The study guide can be used in a number of ways. In its entirety it can be the foundation for a course for non-dental health professionals. It can also be used as a self-study guide by the individual professional. Some sections may be more pertinent for some then others. For example the speech pathologists might be only interested in Section VI Non-nutritive sucking. Finally it can be used as a reference for oral health topics with the references and additional resources at the end of each section a valuable source for additional information. 7

8 I. INTRODUCTION Learning Objectives At the conclusion of this section, the reader should: 1. Understand the relationship between dental and general health. 2. Recognize that oral health can affect a child s quality of life. 3. Describe early oral/dental growth and development. 4. Know when primary and permanent teeth erupt. 5. Describe manifestations of teething ORAL HEALTH AND GENERAL HEALTH AND WELL BEING The mouth can reveal general health status in a number of ways. Because of its easy access, health care professionals are aware of clinical manifestations of infections (herpetic gingivostomatitis), immune deficiency (HIV), nutritional deficiencies (scurvy), medical interventions (radiation mucositis), pharmaceuticals (xerostomia), just to mention a few. The oral manifestations of general health in a pediatric preschool and early school age population can be divided between those affecting the teeth and soft tissues. (Conditions secondary to acute, congenital or hereditary medical diagnoses will not be included in this section). TEETH 1. Early childhood caries is a direct reflection on an infant s diet, inappropriate feeding practices and possibly health status. Another diagnosis failure to thrive, has many manifestations and parents may be feeding the infant cariogenic diets in an attempt to have the infant eat and gain weight. In doing so they are also subjecting the oral cavity to a subtrate that promotes the caries process. 8

9 2. Hypoplastic enamel of primary teeth is usually a manifestation of the mother s general health during pregnancy and not the infants. But hypoplastic permanent first molars and anterior teeth could be the result of an infection or intervention (pharmaceutical) process prior to age three. Children from Third World countries could have had nutritional deficiencies (vitamin D deficiency) resulting in hypoplastic permanent teeth. Products of premature birth and very low birth weight can have hypoplastic enamel in both primary and permanent dentitions due to disturbances during enamel formation and maturation. SOFT TISSUE 1. Disruptions of mucosa integrity of young children can be a manifestation of viral, or fungal infections, side effects of trauma, and the results of pharmaceuticals. The most frequent observations are: A. Viral 1. Acute herpetic lesions Primary acute herpetic gingivostomatitis Recurrent herpes simplex Recurrent herpes labialis 2. Varicella-zoster (chicken pox) 3. The less common: Type A coxsackivirus (hand, foot, mouth disease) Primary HIV infections B. Bacterial Acute necrotizing ulcerative gingivitis 9

10 C. Fungal Candidiasis (overgrowth of candida albicans) D. Trauma Ulceration secondary to tooth eruption Torn frena or buccal mucosa secondary to child abuse E. Pharmaceuticals Gingival overgrowth secondary to phenytoin (convulsive disorders) or cyclosporins. ORAL HEALTH AFFECTING QUALITY OF LIFE Quality of life is a complex issue influenced by cultural and spiritual issues, values, standards, and customs of society. No attempt will be made to address this issue other than to list how young children can be affected by the most common result of oral disease, cavities. 1. Function a. Eating physical inability to masticate food leading to not eating or modifying diets that may not be nutritious and lead to other health problems. b. Smiling unable or unwilling to smile because of appearance. 2. Sleeping young children with severe oral disease are unable to sleep. 3. Absence from daycare or school. 10

11 ORAL AND DENTAL GROWTH AND DEVELOPMENT The oro-facial complex is developed through a series of events that are genetically controlled. Many events are taking place simultaneously or in a sequence that is too involved for this study guide nor is it necessary for the non-dental health professional to have all details. References at the end of this section will provide additional information for those who require more information. Nevertheless, it is important for all health providers to have developmental and growth information to better understand this section of the body. By appreciating normal development you will understand how alterations from normal are possible and when they may have occurred. (See Sections II and III) During the third and fourth weeks of embryonic development the face and mouth form. Three important germ cell layers, ectoderm, mesoderm, and endoderm are all essential in developing parts of the face and mouth. Along with the branchial arches the mouth, lips, parts of the nose and jaws will form between weeks three and six. At the same time development of the palate is taking place that encloses the future tongue which appears at four weeks. Teeth begin (around six weeks) to develop from a band of oral epithelium on the upper and lower jaws. From this tissue tooth buds form and eventually a tooth germ develops with ameloblasts (enamel forming cells) and odontoblasts (forms dentin and pulp). With the dentin mineralizing and enclosing the pulp, the ameloblasts will begin to form enamel. Any time during these developmental stages alterations in the enamel content can affect not only the clinical appearance of the teeth but also its risk for cavities. At birth the infant has deep in its jaws all the primary teeth and many of the permanent teeth at different stages of development. 11

12 Teething (eruption) and exfoliation of teeth will be described together because one is dependent on the other. (See Table I-1) TABLE CHRONOLOGY OF THE HUMAN DENTITION Hard Tissue Root Tooth Formation Begins Eruption Completed Primary Dentition Maxillary Central Incisor 4 mo in utero 7 ½ mo 1 ½ yr Lateral Incisor 4 ½ mo in utero 9 mo 2 yr Cuspid 5 mo in utero 18 mo 3 ¼ yr First molar 5 mo in utero 14 mo 2 ½ yr Second molar 6 mo in utero 24 mo 3 yr Mandibular Central incisor 4 ½ mo in utero 6 mo 1 ½ yr Lateral incisor 4 ½ mo in utero 7 mo 1 ½ yr Cuspid 5 mo in utero 16 mo 3 ¼ yr First molar 5 mo in utero 12 mo 2 ¼ yr Second molar 6 mo in utero 20 mo 3 yr Permanent Dentition Maxillary Central incisor 3-4 mo 7-8 yr 10 yr Lateral incisor mo 8-9 yr 11 yr Cuspid 4-5 mo yr yr First Bicuspid 1 ½ - 1 ¾ yr yr yr Second bicuspid 2 2 ¼ yr yr yr First molar at birth 6-7 yr 9-10 yr Second molar 2 ½ - 3 yr yr yr Mandibular Central incisor 3-4 mo 6-7 yr 9 yr Lateral incisor 3-4 mo 7-8 yr 10 yr Cuspid 4-5 mo 9-10 yr yr First bicuspid 1 ¾ - 2 yr yr yr Second bicuspid 2 ¼ - 2 ½ yr yr yr First molar at birth 6-7 yr 9-10 yr Second molar 2 ½ - 3 yr yr yr 12

13 After Logan and Kronfield: JADA 20, 1933 (slightly modified by McCall and Schour). Copyright by the American Dental Association. Reprinted by permission. Table I-1 Primary teeth generally begin to erupt around six months of age and eruption is completed by 24 to 30 months. Permanent teeth begin eruption between five and six years of age and is usually completed by years of age except for third molars (wisdom teeth) which may never erupt. Variations in tooth eruption from normal times is not unusual and may be familial. Some infants erupt teeth at birth (natal) or shortly after (neonatal) 1 These teeth are rare and the reported prevalence is 1:21 to 1:30,000. Delayed eruption can also occur because of syndromes, developmental defects of teeth, cysts or tumors (see Section III). Girls usually erupt teeth earlier than boys and there are also reports of racial differences. Eruption is usually symmetrical and delays of more than 6-12 months from normal should be evaluated. Variations in infant and toddler behavior, sometimes associated with systemic manifestations are common during teething. (See Table I-2) Reported studies are controversial. In spite of the reports parents often will seek assistance. Whether the symptoms are coincidental or associated with infections, they commonly discontinue with the eruption of teeth. Many palliative remedies are available including teething devices and pharmaceuticals, both systemic and topical. Continuation of symptoms beyond hours should be evaluated by the physician. 2,3 Symptoms Attributed to Teething Irritability Fever Drooling Diarrhea Mouthing Pain Sleep Disturbance Rash Biting Gum rubbing Ear Rubbing Decreased Appetite Table I-2 13

14 Around five to six years of age preschoolers will begin to notice teeth becoming loose and causing discomfort. This may go on for sometime before a tooth is lost the lower front primary teeth being the first usually lost. This process will continue periodically for the next six eight years. Again, variability is common with initiation of exfoliation, the rapidity of loss, the associated discomfort, the retention of very loose teeth, and the loss of the final primary tooth around twelve to fourteen years. It should be noted here, that about the same time the primary teeth begin to exfoliate, the first permanent molars (six year old molars), may be erupting. This occurs without the loss of any primary teeth, far back into the jaws, distal to the last primary molar. Here too there can be some discomfort and irregularities that may require intervention. Early or delayed loss of primary teeth can be a concern and needs to be evaluated. Premature loss of primary teeth before 5 6 years of age can be associated with local factors or systemic problems and require evaluation and possible immediate intervention (see Section II). Delayed exfoliation can also be a concern and may be due to local factors or syndromes. Again, with periodic professional oral care and monitoring of development, intervention can be recommended at appropriate times. As primary teeth erupt the occlusion develops. Here too alterations from normal are common. They too can be due to environmental factors (habits) and/or congenital/hereditary disorders. The occlusion is assessed by having the child bring their jaws together. This is not always a simple task for some children. When requested they may jut their lower jaw forward or bite to one side or the other. With the primary dentition we are most interested in the anterior posterior relationship of the jaws, the horizontal relationships (from cheek to cheek) and finally the anterior position of the upper and lower teeth. (Figure I-3). Variations from normal should be evaluated and depending on the findings, the child and if function is compromised, treatment may be indicated (See Section IX). 14

15 Normal occlusion in the Primary Dentition Figure I-3 REFERENCES 1. Cunha RF, Boer FA, et al. Natal and neonatal teeth: a review of the literature. Pediatr Dent, 2001; 23: Hulland SA, Lucas JO et al. Eruption of the primary dentition in human infants: a prospective descriptive study. Pediatr Dent, 2000; 22: Macknin ML, Piedmonte M et al. Symptoms associated with infant teething: a prospective study. Pediatrics, 2000; 105: ADDITIONAL RESOURCES 1. Enlow DH and Hans MG. Essentials of Facial Growth, W.B. Saunders Company, Philadelphia, Nowak A. The Handbook-Pediatric Dentistry, 2 nd ed. 1999, Chicago, American Academy of Pediatric Dentistry, pp Oral Health and Learning, NCEMCH, MCHB, DHHS, Arlington, VA

16 II. ORAL DISEASE A COMPLEX BACTERIAL INFECTION Learning Objectives At the conclusion of this section, the reader should: 1. Understand that oral diseases are infections. 2. Understand that caries is an infection and that decay is a result of the infection. 3. Know the role of mutans streptococci in the caries process. 4. Be able to describe the biofilm, dental plaque. 5. Describe the formation of lactic acid and its role in the caries process. 6. Describe early childhood caries (ECC) 7. Be able to list risk factors for oral disease. 8. Define gingivitis and periodontitis 9. Understand how oral diseases affects children differently. 10. Understand the consequences of untreated tooth decay. Pathogenesis The two most common dental infections affect the teeth and the gums (gingiva) around the teeth. Both are bacterial diseases, that begin early in life and continue to progress throughout life with high morbidity and the possibility of loss of teeth. Studies in the early 60 s and latter in the 90 s reported that bacteria are transmissible 5, generally vertically from caregiver (most often the mother) to the child. 3 It is important to note that caries (the infection) can be present without cavities being noted. It is only when the infection overwhelms the host that demineralization of enamel begins. 16

17 KEYES CIRCLES Figure II-1 The bacteria involved are many but most frequently the species mutans streptococci are associated with the caries infection and the most often mentioned bacteria in gingival infections are gram negative anaerobes. The bacteria form a complex community on the teeth. This biofilm, called plaque, adheres to tooth surfaces and increases in amount unless disrupted daily. The film is made up of bacteria that can ferment sugars and other carbohydrates producing lactic acids. Continuing production of acid can lead to demineralization of the enamel. If preventive interventions are not in place or initiated early and daily, cavitation (a cavity) will result. Therefore many preventive recommendations attempt to disrupt the process of demineralization, neutralize the acid attack and remineralize the early lesions. (Figure II-1) In pediatric patients the infection begins as soon as teeth erupt (5-6 months of age) and increases in intensity especially in at-risk and vulnerable children. 3 If allowed to continue severe destruction of teeth can occur. This infection is called early childhood caries (ECC) and is associated with feeding practices that include prolonged use of the bottle during the day and night with carbohydrate containing liquids. When the tooth destruction is confined to the upper anterior teeth, it can be referred to as baby bottle tooth decay or nursing decay. 17

18 Not all children with habitual and prolonged use of the bottle are susceptible to the caries infection. Other risk factors have been identified and include tooth enamel abnormalities, altered saliva production and composition, immune defense mechanisms, insufficient or inappropriate exposure to fluoride, absence of daily oral hygiene, lack of professional dental intervention and finally a number of social, educational, and cultural factors. Periodontal disease is also initiated by bacteria in the biofilm. As the biofilm increases the response to the bacterial products is tissue inflammation. Children generally only manifest the mild forms of gingival disease, called gingivitis. The clinical presentation is usually puffy and red tissues surrounding the neck of the teeth. Bleeding of the tissues may be present. Fortunately this inflammatory response is reversible with daily disruption of the biofilm. Localized and temporary alteration of gingival tissue in children may occur secondary to habits, trauma and during the transition from the primary dentition to the permanent dentition. Seldom is there gingival disease with bone loss (periodontitis) in healthy children. 1 When diagnosed it is associated with defects in neutrophil function. (localized juvenile periodontitis and prepubetal periodontitis). 7,10 Gingival overgrowth can occur in children with a medical diagnosis and the required pharmaceuticals. Examples are, seizure disorder (phenytoin); transplants (cyclosporins) and heart disease (calcium channel blockers). These children should be closely monitored by the dental team and appropriate daily hygiene and oral care intervention initiated. Epidemiology Since the 1970 s national surveys have reported on the oral health status of US citizens. For this study guide we will only report on findings of pediatric patients both preschool and school age. (See Table II-2) 18

19 National Studies Of Caries Rates Table II-2 As background information, to measure oral health a number of indices are used. The most common for dental decay is to count the number of decayed, filled, or missing teeth or surfaces. With the primary dentition it is reported as dfmt or dfs. In the permanent dentition it is reported as DFS or DMFT. Recording periodontal disease is more complicated and can either include the degree of gingival inflammation, the number of bleeding points around the gingiva on probing or the amount of bone loss. The occlusion of children is reported by measuring (when the jaws are together), the anterior/posterior relationship of the jaws, the horizontal relationship of the jaws (from cheek to cheek), the position of the upper and lower front teeth, and finally the alignment of the teeth in each jaw. (see Section VI). Because most studies use representative samples from schools, reports of children below age six are less available. Studies from Head Start and WIC children reported that 6.4% of infants one year old had cavities; 20% of two year olds; 25% of three year olds, and 49% of four year olds. In another study of Medicaid eligible children in a school clinic, 56% of children between months had cavities. 2,8 19

20 Federally funded studies most often reported are the National Institute of Dental Research (NIDR) surveys, The National Health and Nutrition Examination Surveys (NHANES I, II, and III), and the National Center for Health Statistics (NCHS) surveys. 9 All give us a good idea of the prevalence of oral disease in given populations conducted by seasoned examiners at different time periods. This allows us to track progress being made in community wide and professionally recommended preventive interventions. In the late 80 s the media reported that based on federal studies, 50% of school aged children never had a cavity. Although true in part, the report, (NIDR ) was only based on findings of permanent teeth and the primary teeth were not included. (See Figure II-3) The report stated that 97.3% of five year olds were free of decay in their permanent teeth while only 15.6% of seventeen year olds were free of decay, clearly demonstrating the progress of decay through the school years. NIDR Caries Study Figure II-3 But how about the primary teeth? In a review of the same data 4, it was reported that over 40% of five year olds had decay in their primary teeth and by age nine the percent with decay was almost 60%, again demonstrating the progress of decay with time and this time in the primary teeth. (Figure II-4) 20

21 Caries in Primary Teeth Figure II-4 So what is known about prevalence of decay in pediatric patients? The good news is that since the 1960 s reduction in decay in pediatric patients has been reduced dramatically probably due to the use of fluorides. (see Section IV). Nevertheless dental decay continues to be one of the most common diseases in children more common than asthma. (See Figure II-5). Dental Caries A Common Disease Figure II-5 21

22 Furthermore we also know that some populations are at greater risk than others. Those being children of families living in poverty, young Mexican American children, some immigrant children, native American infants and toddlers and non-hispanic black children. Early childhood caries (ECC) is reported in six of ten children by age five. A type of ECC, nursing caries or baby bottle tooth decay is reported in up to 10% of children and 50-60% of native American and Eskimo children. 7 No recent national data are available on decay in children with special health care needs but because of increased risk including diet modifications, pharmaceuticals, and daily oral hygiene limitations, it is suggested that their decay rates are at least similar and may be even higher than the general pediatric population. (See Section VIII) Dental diseases can have a number of effects on children. Besides pain and discomfort, oral function, socialization and daily activities can be affected. One study reported annually by the National Health Interview Survey are the disability days associated with selected conditions. In 1996 it was reported that 1,611,000 school days were lost by children 5-17 years old which averages to 3.1 days per 100 children. 7 Little data is available on the prevalence of periodontal disease of young children. Although commonly reported in children by clinicians, gingivitis (the most mild form of periodontal disease) is easily reversed in children with appropriate intervention. Gingival bone loss is uncommon. One study reported 7.6% of four-year-old low-income Hispanic children with bone resorption in addition to high rates of decay. 7 Other Infections Decay that is not treated will progress through the enamel and into the dentin, the layer of tooth with sensory innervations. Complaints of sensitivity and discomfort will follow. Without intervention the disease process will progress through the dentin and into the pulp of the tooth. Discomfort and pain will increase. Pulpitis is a bacteria infection in the pulp and in early stages can be treated and the tooth restored. If allowed to continue the infection can progress out of the tooth into the surrounding bone. It can further progress with 22

23 development of an inter or extra oral fistula that allows for drainage of pus into the oral cavity. If the infection spreads to the surrounding facial tissues, a cellulitis results with swelling and inflammation. The sites can be submandibular or on the face. Cellulitis requires immediate intervention to prevent serious involvement. Treatment involves removal of teeth (if the cellulitis is tooth related), antibiotics and may require incision and drainage. REFERENCES 1. Bernstein E, Delaney JE and Sweeney EA. Radiographic assessment of the alveolar bone in children and adolescents. Pediatr Dent, 1988; 10: Blen M, Narendran S and Jones K. Dental caries in children under age three attending a university clinic. Pediatr Dent, 1999; 21: Caufield PW, Cutter GR and Dasanayake AP. Initial acquisition of mutans streptococci by infants: evidence for a discrete window of infectivity. J Dent Res, 1993; 72: Edelstein BL and Douglass CW. Dispelling the myth that 50 percent of U.S. schoolchildren have never had a cavity. Public Health Reports, 1995; 110: Keyes PH. The infectious and transmissible nature of experimental dental caries. Arch Oral Biol, 1960; 1: National Center for Health Statistics. Current estimates from the National Health Interview Survey. 1996; Series 10, No Hyattsville (MD): Public Health Service; Schenkein HA, Van Dyke TE. Early onset periodontitis: systemic aspects of etiology and pathogenesis. Periodontol 2000, 1994; 6:

24 8. Tang JMW, Altman DS et al. Dental caries prevalence and treatment levels in Arizona preschool children. Pub Health Reports, 1997; 112: U.S. Department of Health and Human Services, National Center for Health Statistics. National Health and Nutrition Examination Survey III, , Series 11, No. 1. Hyattsville, MD, U.S. Department of Health and Human Services. Oral Health in America: A report of the Surgeon General. Rockville, MD. USDHHS, NIDCR, NIH, Van Dyke TE, Horoszewicz HV et al. Neutrophil chemotaxsis dysfunction in human periodontitis. Infect Immun, 1980; 27: ADDITIONAL RESOURCES 1. Tinanoff N, Ed. Proceedings: Conference on Early Childhood Caries Community Dent Oral Epidemiol 1998; 26; Supplement 1:

25 III. COMMON PEDIATRIC ORAL PATHOLOGY Learning Objectives: At the conclusion of this section the reader should: 1. Recognize healthy oral soft and hard tissues 2. Be able to perform an oral screening examination 3. Recognize common oral soft tissue pathology in infants and toddlers. 4. Describe anomalies of teeth. 5. Recognize disruptions of enamel formation. 6. Describe amelogenesis imperfecta and dentinogenesis imperfecta. 7. Recognize common intrinsic and extrinsic enamel stains and their etiology. Recognizing Normal Healthy Oral Soft and Hard Tissues To recognize abnormalities in the child s mouth it is important to recognize the hard and soft tissues in their normal, non-diseasesd presentation. Without dental radiographs it will not be possible for non-dental health professionals to observe either healthy or diseased hard tissues except for the crowns of teeth that are readily accessible to all clinicians. Even with the crowns visible it will be difficult to observe the proximal surfaces of crowns because of their close proximity to each other and the lack of dental radiographs. The Oral Screening Examination Essential to assessing the oral cavity is access and light. A mouth mirror and tongue blade are helpful. Access will vary with the age of the child and cooperation. For infants and toddlers the knee-to-knee position allows for visibility and stability. (Figure III-1) With older toddlers and school aged children the use of the examining table 25

26 Oral Exam of the Infant/Toddler Figure III-1 with the child in the supine position will work well. A flashlight or an overhead lamp should provide adequate light to illuminate the mouth. Disposable mouth mirrors and tongue blades will both facilitate observing teeth and tissues as well as guiding the tongue to positions that will not block visibility. Lips, tongue and mucosa will be the first soft tissues observed. Lips should be intact, soft, pink, and moist (Figure III-2). Healthy Oral Soft Tissues Lips and Tongue Figure III-2 26

27 If possible the tongue can be grasped by a small 2x2 gauze. It too should be pink, moist and intact. It should be free of deposits on the superior surface. It should not be smooth but have a pebbly surface. When squeezed it should be firm but without hard lumps. The ventral surface will be smooth and vascular. The oral mucosa is non-keratnized tissue and covers the insides of the cheeks almost to the teeth. The color can be pink to brown depending on the skin color. The mucosa should be moist, smooth and intact (Figure III-3). Healthy Oral Soft Tissues Mucosa Figure III-3 In infants and toddlers it will be common to observe strips of tissue from the oral mucosa extending down to and attaching onto the tissues near the teeth. The most common are located in the upper jaw. They are called frena. The most common being in the upper jaw midline between the area of the two front teeth. The other common frenum is on the ventral surface of the tongue and is called the lingual frenum. The skin next to the teeth is gingiva and is keratnized. This tissue will also be pink and form a tight smooth collar around each tooth. It too should be moist and not spongy. If pressed it should not bleed. (Figure III-4). During the transition from the primary teeth to the permanent teeth, the gingival tissues may have rolled edges especially with the anterior teeth. until the permanent teeth are fully erupted. 27

28 Healthy Oral Soft Tissues Gingiva Figure III-4 To observe the palate, with the child in the supine position, the head must be bent back for better access by the clinician. With the light directed onto the surface of the palate one should observe pink, moist and intact surfaces. Forward and towards the anterior teeth, rows of tissue (rugae) will be present, varying in height. (Figure III-5) About two thirds back onto the palate will be an area dividing the hard palate from the soft palate. The tissue will be pink, smooth and soft. Hanging from the rear of the soft palate will be the uvula. If Y shaped it is called a bifid uvula. Healthy Oral Soft Tissues Palate Figure III-5 28

29 The facial bones should be examined first by observation to check for gross swellings and symmetry. Then they should be palpated for tenderness, irregularities and hardness. Further examination will not be possible without radiographs and are only ordered if there are signs, symptoms or a suspicious history. The major salivary glands are located in the cheeks (parotid) and the floor of the mouth, submandibular and sublingual glands. The ducts will be raised and pink. Observation and palpation are used to examine the glands. It is common to observe secretions from the glands and they should be clear. Palpation should not elicit discomfort. Only the crowns of teeth will be observed. Without dental instruments only a gross examination can be performed. Nevertheless the clinician should be able to observe three of the five crown surfaces and the remaining two (proximal surfaces) partially. (Figure III-6) Healthy Teeth Figure III-6 The examination should begin by counting teeth. When all erupted there should be twenty primary teeth. The primary teeth are white in color, opaque, with smooth intact surfaces except for the biting surfaces of posterior teeth that will have a series of grooves and pits. Permanent teeth are cream colored and translucent when observed next to primary teeth. In most cases they are also larger. The number visible to the clinician will vary with the child s age and development. 29

30 SOFT TISSUE PATHOLOGY Only common soft tissue lesions of infants and toddlers and young school children will be described in this section. Treatment choices, intervention or referral will be suggested. For further in-depth review of pediatric oral pathology references are listed at the end of this section. Shortly after birth and at the first examination the physician or nursing staff may note round white nodules on or near the midline on the palate or on the alveolar ridges. Epstein s Pearls Figure III-7 These are EPITHELIAL CYSTS (Epstein s pearls palate; Bohns nodules alveolar ridges). They usually spontaneously exfoliate and require no treatment. (Figure III-7) A localized pedunculated or sessile smooth surface pink to red in color lesion may be present at birth usually in the upper anterior jaw. The CONGENITAL EPULIS may cause feeding problems and may be excised depending on its size and interfering with function. (Figure III-8) 30

31 Congenital Epulis Figure III-8 In infancy the tongue, buccal mucosa and palate may be coated with a soft white plaque. If able to be removed with a gauge pad or tongue blade and a red raw undersurface is noted the diagnosis most likely is PSEUDOMEMBRANOUS CANDIDIASIS (Thrush). This fungal infection should be treated with antifungal medication. (Figure III-9) Thrush Figure III-9 At birth or shortly after there may be a tissue swelling in the midline of the lower jaw. Upon palpation calcified tissue may be noted or there may be a tooth like object visible. These are NATAL TEETH (at birth) or NEONATAL TEETH (after birth) and 90% of the time are one of the primary teeth and not a supernumerary (extra) tooth. Usually poorly formed and quite mobile, they can interfere with feeding and consideration should be given 31

32 to extract. To date no report of tooth aspiration has been reported in the literature. (Figure III-10) Natal Teeth Figure III-10 A bluish, translucent, elevated, compressible lesion may appear on the alveolar ridge at the time of an erupting tooth. The ERUPTION CYST or ERUPTION HEMATOMA is blood or fluid filled and may cause discomfort. If the lesion interferes with function, intervention should be considered with surgical deroofing as a possible treatment. Before surgical treatment a HEMANGIOMA should be ruled out. (Figure III-11) Eruption Hematoma Figure III-11 32

33 A mucosa ulcer secondary to trauma may be noted in infants and toddlers. TRAUMATIC ULCERATION on the ventral surface of the tongue in infancy has been referred to as RIGA FEDE S DISEASE and is due to irritation from the erupting mandibular anterior teeth. Symptomatic treatment is usually recommended (Figure III-12). Traumatic Ulcer Figure III-12 Other ulcers can be due to trauma, accidental or aggravated (child abuse) or herpes simplex virus, (HERPETIC ULCERS), systemic deficiencies and/or probable immune defects (APHTHOUS ULCERS). Most often located on non-kerantinized movable tissues with a crater surrounded by erythematous halo (except for ulcers secondary to a blunt object or a force as in child abuse). Ulcers can be painful especially when eating and talking with symptomatic relief recommended and healing in usually 7-10 days. (Figure III-13) 33

34 Herpetic Ulcer Apthous Ulcer Figure III-13 HERPETIC ULCERS usually are proceeded by prodromal tingling followed by vesicles that coalesce into a small ulcer without an erythematous halo. They are usually located on the hard palate, the vermilian border of the lips and the attached gingival tissue. Healing occurs in 7-14 days and intervention is symptomatic. Two common tumor-like raised lesions are a FIBROMA with usually a pedunculated firm surface; and usually located on the mucosa, lips, or tongue. A PAPILLOMA has a soft pedunculated cauliflower like surface, is pink to white in color, and is usually a solitary lesion that can be located almost anywhere in the mouth. Surgical excision is the usual treatment of choice for these tumors with recurrence uncommon. (Figure III-14) Fibroma Papilloma Figure III-14 34

35 A localized, compressible, fluid filled nodule with smooth surface, fluctuating in size and clear to bluish in color is called a MUCOCELE (mucous retention phenomenon). If found on the floor of the mouth it is a RANULA and is associated with the sublingual salivary gland. Recurrence is common if not completely excised. Marsupalization is treatment of choice for the ranula. (Figure III-15) Mucocele/Ranula Figure III-15 A wide spread oral and perioral infection associated with fever, discomfort, malaise, lymphadenopathy, intense red gingival and multiple vesicles located throughout the mouth that rupture resulting in ulcers, drooling and halitosis is PRIMARY HERPETIC GINGIVOSTOMATITIS. It is a self-limiting disease secondary to the Herpes Simplex Virus (HSV) with dehydration and high temperatures a major concern. Supportive therapy, hydration, and antipyretics are indicated. It usually resolves in 7-10 days. (Figure III-16) 35

36 Primary Herpetic Gingivostomatitis Figure III-16 A lingual frenum is usually attached at the base of the tongue. When attached to the ventral tip of the tongue it may restrict tongue movements causing ANKYLOGLOSSIA. (tongue tied). In extreme cases feeding problems have been reported. Most infants adapt early. Frenectomy may be indicated. (Figure III-17) Ankyloglossia TOOTH ANOMALIES Figure III-17 HYPERDONTIA refers to an excess number of teeth. As a reminder when eruption is complete there are twenty primary teeth and 32 permanent teeth. Occasionally you may note an extra primary tooth after counting teeth. Although most common with the 36

37 permanent dentition they can be present in the primary dentition. An extra tooth is called a SUPERNUMERARY TOOTH. If localized in the midline of the upper jaw it is called a MESIODENS. More often they are not visible clinically and only are diagnosed when a radiograph is ordered secondary to the recommended guidelines for the ordering of radiographs or because of delayed exfoliation or eruption. (Figure III-18) Supernumerary Teeth Figure III-18 HYPODONTIA (oligodontia) refers to congenitally missing teeth and is usually diagnosed when counting the teeth erupted and present. Hypodontia is most often correlated with a familial pattern. It is generally uncommon in the primary dentition unless a diagnosis of ECTODERMAL DYSPLASIA is also considered. (Figure III-19) 37

38 Ectodermal Dysplasia Figure III-19 FUSION and GEMINATION although rare (0.5%) can be noted upon examination and are more common in the primary dentition. Generally radiographs are necessary to differentiate the two, with fusion being two individual teeth being fused and gemination a single tooth bud that develops into a bifid crown with only one root. (Figure III-20) Fusion Gemination Figure III-20 Teeth may have extra cusps. The most common is a large cusp on the back (lingual) surface of the upper front teeth but can also be found on posterior teeth. When found on the anterior teeth it is called a TALON CUSP. (Figure III-21) 38

39 Talon Cusp Figure III-21 ENAMEL AND DENTIN DYSPLASIAS A disruption during the stages of tooth development may affect the enamel. Generally this is referred to HYPOPLASIA (insufficient quantity of enamel) or HYPOCALCIFICATION (enamel quantity normal but quality of enamel is poor) and can either be a heritable defect or one induced by the environment. (Figure III-22) Hypoplasia Hypocalcification Figure III-22 The common heritable defect is AMELOGENESIS IMPERFECTA (AI) with an incidence of one in fourteen thousand or as high as one in There are four types AI with the hypoplastic (type I) and hypomaturation (type II) being the most common. There 39

40 are 14 different sub-types of AL and the pattern of inheritance varies from one type to the next. The most common forms are generally inherited as an autosomal dominant or x- linked traits. Both dentitions are affected. Superimposed decay is common around the defects, because of the poor quality or absence of enamel. (Figure III-23) Amelogenesis Imperfecta Figure III-23 HYPOPLASIA can also be induced environmentally from systemic or local causes. Severe nutritional deficiencies, infection and rubella all can interfere with enamel development and lead to a defect in the enamel. A type of hypoplasia is FLUOROSIS, caused by excessive high amounts of ingested fluoride during tooth development. Fluorosis may range from mild, with lacy white mottling of teeth to severe with pitting and brown staining. Trauma in a localized area during tooth formation can result in one or few teeth being hypoplastic while all remaining teeth will have normal enamel. A heritable defect of dentin (inner layer of the tooth) is DENTINOGENESIS IMPERFECTA (DI) that originates very early in tooth development and is a defect in the dentin matrix. Incidence is 1:8000 and is reported as one of three types, Shields Types I, II, or III. All types are inherited as an autosomal dominant trait. Shields Type I is associated with OSTEOGENESIS IMPERFECTA and the crowns have an amber translucent color. Shields Type II is known as HEREDITARY OPALENCENT DENTIN is very similar in 40

41 appearance to type I but does not occur with OI. Shields Type III is very rare and the teeth have a shell like appearance that have frequent pulp exposures. (Figure III-24) Dentinogenesis Imperfecta Figure III-24 Enamel color can also be affected either extrinsically or intrinsically. EXTRINSIC COLORATION is normally due to environmental stains and are more apt to occur when teeth are covered with biofilm and toothbrushing is irregular or not practiced. A very common extrinsic stain is a black stain on the crowns of teeth. History usually reveals that the child is anemic, on a liquid iron supplement and the teeth are not brushed by the caretaker. (Figure III-25) Extrinsic Staining Figure III-25 41

42 INTRINSIC STAINS are due to blood borne pigments (for example congenital porphyeria, drug administration, tetracycline antibiotics from inter-uterine development to eight years of age). Excessive fluoride can also cause intrinsic stain (from diffuse white spots to brown mottling) with or without hypoplastic defects. REFERENCES 1. Acs G. Oral manifestations of systemic diseases, Pediatric Basics, Winter 1998; 82: Dummett CO. Anomalies of the developing dentition, in Pediatric Dentistry Infancy Through Adolescence 3 rd ed. Pinkham, J Ed. Philadelphia: W.B. Saunders Co., 1999; Flaitz C. Oral pathologic conditions and soft tissue anomalies in Pediatric Dentistry Infancy Through Adolescence 3 rd ed. Pinkham, J. Ed, Philadelphia: W.B. Saunders Co, 1999; Laskaris G. Color Atlas of Oral diseases in children and adolescents. New York: Thieme Stuttgart, ADDITIONAL RESOURCES 1. The Handbook Pediatric Dentistry 2 nd ed. Nowak AJ 1999, Chicago, American Academy of Pediatric Dentistry, pp

43 IV. INFANT AND TODDLER ORAL HEALTH MANAGEMENT Learning Objectives At the conclusion of this section the reader should be able to: 1. Understand the importance of scheduling an oral health evaluation between months of age. 2. Identify infants and toddlers at risk for oral disease based on risk factors. 3. Perform an oral screening of infants and toddlers. 4. Clinically recognize dental plaque, white spots, decalcification and cavities. 5. Provide age appropriate and developmentally based information to parents on oral health. (anticipatory guidance) 6. Encourage a Dental Home for children for routine preventive interventions, monitoring of oral facial growth and development, emergency care if needed and a personalized periodic recall schedule. Rationale for First Oral Examination Early intervention and risk assessment are essential components in assuring that oral health is an outcome for all children. Early, frequent and periodic preventive visits have been promoted by the American Academy of Pediatrics through their preventive health care guidelines 3. Eight visits are recommended in the first year of life; and five visits during the period from 15 months to four years. The Bright Futures Guidelines 4 promotes similar scheduling of preventive health visits. Both guidelines emphasize the early recognition of problems and the prevention of problems through appropriate counseling and interventions. As explained in Section II, oral disease is a bacterial infection with an early initiation. The mouth of infants become infected at birth with bacteria and at the time teeth are erupting 43

44 colonize on the tooth surfaces. Therefore the time to initiate preventive strategies is during tooth eruption. By assessing the risk of the infant and providing appropriate recommendations, disruption of the disease process can begin. Unfortunately there is no immunization to give an infant to prevent oral disease. However conducting a thorough history, providing an oral screening and evaluating parenting attitudes and skills an assessment can be made on the infant s future risk to disease. Home care instructions can be outlined and demonstrated. In summary, the optimal time for the early oral intervention is at the time the bacteria are inoculating the oral cavity. (at the time of tooth eruption) 2,5 Because infants are scheduled generally with the primary care provider at 6, 9, and 12 months of age these are ideal visits to include a preventive oral health component to the usual medical procedures planned. Identifying at risk infants Presently there are no diagnostic laboratory tests to order to determine if the infant is at high risk for oral disease. Attempts have been made to use strep mutans (see Section II) levels as an indicator for risks. But in the absence of other factors a high strep mutans count alone does not insure a risk status. 1,2 From many reported studies the most noteworthy risk factors for oral disease are: 1. Presence of plaque on infant s teeth. 2. Absence of fluoride exposures. 3. Presence of cavities and white spot lesions. 4. Parents SES. 5. High sucrose containing diet. 6. Nationality Other risk factors identified are mother s diet during pregnancy; mother s oral health status; prolonged and inappropriate use of nursing bottle or breast; family history of oral disease; 44

45 salivary flow rate; salivary buffering capacity; infants oral medications; and some medical diagnoses. 1 Because of the broad range of risk factors, the primary care provider should consider the infant/toddler at risk until proven otherwise. Once the risk for oral disease has been assessed, interventions and monitoring can be established and maintained unless a change takes place in the child s health history. It has been suggested that children with special health care needs may be at higher risk for oral disease. No studies are available to confirm this. But experience has shown that these children may have developmental, feeding and medication factors that increased their risk. For example, anomalies of tooth enamel will allow plaque and food to adhere more firmly making daily hygiene difficult. With less enamel, a protective layer is missing allowing demineralization to rapidly proceed. Conducting the examination The examination provided by the non-dental health professional is a screening type examination. Nevertheless it is an important examination for purposes of demonstrating to the caregiver growth and development of the infant s mouth and determining if any signs of disease are present. 6 For very young infants no dental chair or table are necessary. The doctor and caregiver make a cradle to comfortably support the child by sitting face to face on chairs and joining knees. With the child comfortably in the cradle and the head in the lap of the doctor, the parent can support the infant. With a gloved hand, lips can be lifted, soft tissues can be palpated and the tongue compressed. A dental mouth mirror will be very useful to direct light on the posterior areas of the mouth. The examination should note tooth irregularities and alignment. (See Section III) Plaque and debris should be observed on the teeth and demonstrated to the caregiver. Recommendations for daily removal with the appropriate style toothbrush should be made. 45

46 An examining light can be used by the examiner to illuminate the mouth. There are many available in most health professional offices and in lieu of one available a flashlight can always be used and held by the caregiver. Any findings from normal should be discussed and a recommendation to schedule a dental visit with the pediatric dentist made. (Figure IV-1) Composite Photo Of normal primary dentition And negative findings Figure IV-1 46

47 Anticipatory Guidance Upon the completion of the oral screening a discussion of future growth and development should be initiated (See Appendix). 7 Age appropriate information either in written or oral form can be provided to the caregiver. The Bright Futures program has appropriate anticipatory guidance information available for each stage through adolescence. 1 The Dental Home The Dental Home is a family centered, community based, accessible program that provides continuous, comprehensive, coordinated and culturally competent oral health supervision intervention for all children. All children should have a dental home as soon as the teeth begin to erupt. The Dental Home can best embrace early intervention with prevention of disease and oral health as a goal. At the same time in those situations where an accident may take place and involve oral and dental tissues, the immediate attention to the problem with a practitioner who is familiar with the child can reduce/eliminate the usual anxiety of an accident and increase the chances of a positive outcome. 8 In the Dental Home tracking and sequencing of preventive intervention can be easily accomplished. Based on the specific needs of the child a personalized schedule can be developed and presented to the parent. The personalized follow up schedule is based on the risk of the child to dental disease as well as developmental milestones. For example by 30 months of age we would expect all primary teeth to have erupted and in occlusion. By 5 ½ years of age we would expect primary teeth to begin to loosen and first permanent molars to erupt. These are just two examples of milestones that should be considered when scheduling follow up appointments. 47

48 References 1. Bright Futures in Practice: Oral Health. Casamassimo, P.C., ed. Arlington, Virginia: National Center for Education in Maternal and Child Health Caufield PW and Griffen AL. Dental Caries An Infectious and transmissible diseases. Ped Clin NA, 2000; 47: Committee on Practice and Ambulatory Medicine, Recommendations for Preventive Pediatric Health Care, American Academy of Pediatrics. Pediatrics, 2000; 105: Green M, Pafrey JS, eds Bright Futures: Guidelines for Health Supervision of Infants, Children and Adolescents, 2 nd ed. Arlington, VA: National Center for Education in Maternal and Child Health. 5. Nowak AJ. Rationale for the timing of the first oral evaluation. Pediatr Dent, 1997; 19: Nowak AJ and Warren JJ. Infant Oral Health and Oral Habits. Ped Clin NA., 2000; 47: Nowak AJ and Casamassimo PS. Using anticipatory guidance to provide early dental intervention. J Am Dent Assoc, 1995; 126: Nowak AJ and Casamassimo PS. The dental home a primary care oral health concept. J. Am Dent Assoc, 2002; 133: Additional Resources 1. The Handbook Pediatric Dentistry, 2 nd ed, Nowak A. Ed, American Academy of Pediatric Dentistry, Chicago, 1999, pp

49 2. Infant oral Health Guideline American Academy of Pediatric Dentistry, Pediatr Dent, 2001; 23 (Reference manual), p

50 V. PREVENTION Learning Objectives: At the conclusion of the section the reader should be able to: 1. Discuss plaque (biofilm) and its role in oral diseases 2. Discuss when to initiate cleaning teeth 3. Describe methods to remove plaque from teeth. 4. Discuss the anticariogenic properties of fluoride 5. Understand the effects of excessive fluoride and the outcome of fluorosis 6. Describe the effects of inappropriate feeding habits (prolonged use of bottle) and oral health 7. Discuss the problem of snacking and its role in oral health Introduction In Sections II and IV background information was provided on the complex bacteria infection, oral disease, identifying infant/toddlers at high risk and initiating a personalized oral health prevention strategy. It is important for non-dental health practitioners to understand the basic concepts and historically proven preventive methods that have been available to the profession to decrease the negative outcomes of dental disease. To date all preventive interventions recommendations are based on principles established by early researches and most noteworthy the work of Keyes 7. (See Section II) Because dental disease is a bacteria infection, all interventions are aimed to affect the causative bacteria, increase the resistance of the host (teeth and gums) and reduce the substrate required by bacteria. 50

51 This section will address those concepts primarily in the preschool child, where the primary care provider can have an influence in recommending preventive strategies. By five years of age the majority of children will have had a first professional dental intervention and the pediatric dentist or family dentist will be supervising the oral health of the child. Plaque Plaque (biofilm) is a sticky film of many bacteria, food debris and salivary components that adhere to the tooth. General components of plaque are calcium and phosphorus. The cariogenic bacteria produces polysaccharides that improve adherence of the plaque to the tooth enamel. Although plaque can initially protect enamel because of its mineral content, if left undisturbed, it will increase in size and in the number of bacteria. When a substrate is available, such as sugars and other fermentable carbohydrates, an acid is produced that attacks the enamel with loss of calcium and phosphate. This initial demineralized area is referred to as a white spot lesion. Depending on many factors including saliva ph, presence of fluoride, removing plaque and modifying the substrate, this lesion can either become remineralized or with time lead to cavitation. Plaque Removal Plaque removal should begin early as soon as teeth erupt. Some reports suggest wiping the edentulous alveolar ridges with a washcloth or wet gauze. There is no evidence in the literature that would suggest this is of any preventive value. Cariogenic bacteria requires tooth surfaces to adhere too and do not adhere to tissue. Possibly an advantage of wiping the alveolar ridge would be to begin to develop a habit of oral hygiene. Again there are no reports to suggest that infants who have had their edentulous alveolar ridges wiped leads to better oral hygiene after the teeth erupt. Plaque removal is a fine motor activity in infants, toddlers, and even preschoolers cannot be expected to perform this activity initially. Therefore the care provider will be responsible for cleaning the teeth. With proper positioning and a toothbrush that is comfortable for the caregiver to use, removing plaque can be fun and quickly accomplished. With increasing number of teeth more time will be necessary. 51

52 Initial brushing of teeth can be accomplished in the bath, on the changing table or in a setting where two adults sitting knee to knee create a cradle for the infant to lie in. In this supine position there is stability and good access to the oral cavity. With gentle pressure from fingers, the jaws can be spread apart and the brush inserted for cleaning. Minimal if any fluoride containing toothpaste should be used and a system developed to try and clean all surfaces of the teeth. (Figure V-1) Parents in Knee to Knee Position Brushing Teeth Figure V-1 With increasing number of teeth, more time will be necessary to clean the teeth. Infants and toddlers will want to hold the brush and mimic this activity. An appropriate size brush with wide handle can be given to the child to use. But this does not replace the caregivers careful brushing. A rotary scrubbing method is probably the preferred motion to use for brushing teeth. It is recommended to initially brush once a day preferably before bedtime to disturb and remove the plaque off the teeth. As children age, learning to brush after meals and/or before going to school is recommended. Most childcare centers will also encourage toothbrushing as one of the many daily personal hygiene activities. Toothbrushes There are hundreds of styles of manual brushes available to choose from. More recently power brushes have become popular but none are recommended for infants. 52

53 Select a brush appropriate for the size of the mouth and the brusher. Initially the caregiver is the primary brusher and a brush with a longer handle will be more comfortable. Because of the few teeth and a small oral cavity, a smaller head will be most convenient. Soft bristles should always be selected over coarse or hard ones. Colors and logos are up to the selection of the caregiver and child. Brushes should be stored properly to dry between brushings. They should also be replaced periodically depending on their use. Flossing is very difficult in young children because of the size of the mouth and the cooperation expected. Preferences are to concentrate on brushing well; with flossing coming much later in the child development. Contemporary Use of Fluoride The beneficial oral health affects of the mineral fluoride are well known and has been documented in thousands of reports in the literature. 1 For the non-dental health professional or practitioner it is important to know fluoride is safe when used appropriately. The element fluorine is found naturally throughout the world. Early studies demonstrated that when incorporated in the tooth, the demineralizing effects of acids were reduced. 3 With the beginning of water fluoridation in 1945, there began a lengthy series of studies and reports to again show the beneficial effect in reducing cavities and improving oral health. The effects of fluoride on teeth and the subsequent reduction in cavities has been thought to be the result of the preeruptive corporation of fluoride in the developing tooth enamel. With continuing research and a better understanding of the caries process, it is now believed that the predominant effect is post eruptive and not preeruptive with incorporation of the fluoride into the demineralized tooth surfaces. 1 53

54 There are many products and methods available for the systemic and topical application of fluoride. Some are available for self-application and others for application by a professional. (see Table V-1) Fluoride Therapy Topical Systemic 1. Professionally applied 1. Fluoridated water A. Gels, foams, solutions B. Varnish 2. Supplements 2. Self applied A. Tablets/lozenges A. Rinses B. Drops B. Gels C. Vitamin combinations C. Tablets/lozenges D. Dentifrices D. Dentifrices 3. Fluoridated water Table V-1 It is the responsibility of the health professional to select the most appropriate fluoride, the right amount and to be given at the right time. Fluorosis Ingestion of an inappropriate amount of fluoride at a time of enamel calcification can adversely effect formation of enamel crystals. This leads to hypomineralization of dental enamel affecting the porosity of the enamel. This is called fluorosis. Clinically it can appear as a very mild chalk like, lacy marking across a tooth surface to a severe form where the enamel is pitted and brittle and heavily stained. (Figure V-2) 54

55 Fluorosis Mild Moderate Severe Figure V-2 Fluorosis occurs only when fluoride is ingested during critical periods of tooth development. It is highly dependent on the dose, duration, and the timing of the fluoride intake. The transition and early maturation stages of enamel development appear most susceptible to fluoride. For the anterior permanent teeth, the critical period is estimated at months for boys and months for girls. 4 Fluorosis of primary teeth is uncommon. When seen clinically the second primary molar, buccal surfaces are most often involved. Because the second primary molars are calcified post-natally it is suggested that the fluoride is associated with water fluoride concentration and not from fluoride dentifrices or fluoride supplements. Fluoride Recommendations Current recommendations for the optimal oral health effect are based on the risk of the child for oral disease (see Section IV), the known outcome of excessive systemic fluoride in preschool children, and the availability of fluoride containing products. 1. Fluoridation of Community Waters The most cost effective method to prevent cavities in populations served by community waters is by addition of fluoride. Note: the effects of the use of bottled and processed waters over community waters and caries prevention is not known. Most bottled and 55

56 processed water do not contain fluoride and manufacturers are not required to state the fluoride (if any) content. 2. Fluoride containing toothpaste Over 95% of toothpaste for sale in the United States contain fluoride. There are no child version fluoride toothpastes with reduced fluoride content. The only way to limit fluoride uptake from toothpaste is to limit the amount placed on the brush. Present recommendations are a small pea sized amount and maybe only a smear. (Figure V-3) Toothbrushes With different Amounts of Toothpaste Figure V-3 For preschoolers, the caregiver should place the paste on the brush. Because of inadequate developed control of the swallowing reflex in children under six years and even less controlled in children under three years, it is possible for preschoolers to swallow as much as 0.8 g of toothpaste per brushing which amounts of 0.8 mg of fluoride Fluoride supplements 56

57 Children at high risk for dental disease and who drink low fluoride or no fluoride water may be prescribed a supplement in the form of a pill or lozenge. Schedules are periodically updated by the ADA, AAP, and AAPD. (Table V-2). Fluoride Supplementation Schedule Water Fluoride Concentration (ppm)* Age < >0.6 Birth < 6 months months < 3 years years < 6 years to at least 16 years *1.0 ppm = 1 mg/liter mg sodium fluoride contains 1 mg fluoride ion Table V-2 The water used by the family should first be analyzed for fluoride content (See Appendix for testing programs) and then the appropriate supplement dose prescribed. It is also suggested to allow the tablet/lozenge to dissolve slowly in the mouth for a topical effect. The preferred time is after brushing the teeth and before going to bed at night. This allows the fluoride rich saliva to bathe the teeth for an optimal topical effect. 4. Application of high concentration fluoride products The use of topical products containing fluoride are either available for professional applications or for self-application. Professional application of high concentration fluoride should be limited to children at high risk of dental disease and not as a routine intervention for all children. Most recently, in the United States, the application of a fluoride varnish in preschoolers at high risk or with early signs of dental 57

58 disease has been promoted. This application is quite simple, fast, and reduces the amount of fluoride that is available to the child for ingestion. Scandinavian studies have shown fluoride varnish to be cost effective in the school dental services 12. Fluoride mouth rinses are available over the counter without prescription for daily use. Because children under six years may have uncontrolled swallowing reflex they are not recommended. But for school aged children who are at high risk, the daily use of a fluoride containing rinse should be considered. Whatever fluoride regimen is recommend, monitoring is important. As children age and if risk status changes, modifications in fluoride dosage may need to be made and further monitored. DIETARY GUIDELINES Because dental disease is a complex bacterial disease that requires a susceptible host, cariogenic bacteria and a substrate for the bacteria to survive, a preventive strategy must include monitoring and possibly modifying the child s diet. Balanced nutrition is important for healthy gums and teeth. It is not the intent of this section to elaborate on the healthy diet for optimal growth and development for children. All fermentable carbohydrates provide the required nutrients for oral bacteria to metabolize and produce acids that can promote oral diseases. How an individual child is affected by these acids will depend on many factors including the susceptibility of the teeth and the ability of saliva to neutralize the acid. (Table V-3) 58

59 Relative Decay Potential of Beverages Source Relative Decay Potential Standards Water % sucrose solution 1.00 Human breast milk Human breast milk alone 0.01 Human breast milk with 10% sucrose 1.30 Formula ProSobee 1.11 Gerber-Fe 0.80 Isomil 0.79 Enfamil-low Fe 0.74 Lactofree 0.68 Carnation Followup 0.62 SMA-Fe 0.62 Enfamil-Fe 0.57 Next Step 0.51 Similac-Fe 0.51 SMA-low Fe 0.51 Gerber-low Fe 0.45 Gerber-Soy 0.45 Similac-low Fe 0.29 Carnation Good Start 0.01 Nursoy 0.01 Alsoy 0.01 Other beverages Yo-J 0.32 Apple Juice 0.80 Orange Juice 0.85 Grape Juice 0.74 Fruit drinks 0.93 Soda pop 1.05 Personal communication, P.R. Erikson, 1999; and data from references 5 and 6. Table V-3 59

60 Unfortunately inappropriate dietary habits begin early in life with parents who are ill prepared in parenting skills and do not use common sense. Even though infants must be fed frequently during their first year, carrying this schedule into the second and third years with frequent bottles and snacks as a substitute for healthy nutritious meals has become common. It is important for all health practitioners to discuss with parents the prolonged and inappropriate use of the bottle after teeth have erupted. Toddlers do not require a bottle hanging out of their mouth day long. This bottle, if containing a beverage with a fermentable carbohydrate, will feed the bacteria and set up an unhealthy oral environment placing the child at high risk for oral disease. Guidelines suggest that weaning from the bottle should occur at 12 months of age. 9 Beverages other than milk and water are inappropriate to feed a toddler on a routine basis. Carbonated beverages are especially troublesome not only because of their carbohydrate content but also the low ph. There are no published guidelines that suggest toddlers have soda pop from a bottle. Fruit juices and drinks can also be a problem not only for oral health but for general health. Juices should not be used in the bottle but only after a child can hold a cup and drink in the upright position. 2 Availability of confectionaries and baked goods should be limited and children can be directed to eat appropriate fruits and vegetables for snacks. Sweets should be reserved for weekly junk nights and special occasions. (Table V-6) Suggested Snacks For Oral Health Fresh Fruits Raw Vegetables Cheese Milk Yogurt Fruit Juices Popcorn Water 60

61 Table V-6 With increase in age and socialization, children will be provided treats at daycare, friends homes and parties. Parents should be proactive and work to find an acceptable balance between acceptable and unacceptable foods. REFERENCES 1. Clarkson BH, Fejerskov O, Ekstrand J, Bart BA. Rational use of fluorides in caries control. In Fejerskov O, Ekstand J, Burt BA, eds. Fluorides in Dentistry 2 ed. Copenhagen: Munksgaard, 1996; Committee on Nutrition. The Use and misuse of fruit juices in pediatrics. American Academy of Pediatrics. Pediatrics, 2001; 107: Dean HT, Arnold FA, Jay P and Knutson JW. Studies on mass control of dental caries through fluoridation of public water supply. Public Health Rep, 1950; 65: Den Besten PK, Thariane H. Biological mechanisms of fluorosis and level and timing of systemic exposure to fluoride with respect to fluorosis. J Dent Res, 1992; 71: Erikson PR, Mayhari E: Investigation of the role of human breast milk in caries development. Pediatr Dent. 1999; 21: Erickson PR, McClintock K et al: Estimation of the caries risk associated with infant formulas. Pediatr Dent; 1998; 20: Horowitz HS, Ismail L. Topical fluoride in prevention. In: Fejerskov O, Eckstrand J, Burt BA eds. Fluorides in Dentistry 2 ed. Copenhagen: Munksgaard, 1996; pp

62 8. Keyes PH. The infectious and transmissible nature of experimental caries. Arch Oral Biol. 1961; 1: Levy SM. A review of fluoride intake from dentifrice. J Dent Child, 1993; 60: Pediatric Nutrition Handbook. 4 th ed. Kleinman, RE ed. Elk Grove Village, American Academy Pediatrics; 1998: Schafer TA and Adair SM. Prevention of Dental Disease the role of the pediatrician. Ped Clin NA, 2000; 47: Seppä L, Tolonen T. Caries preventive effect of fluoride varnish applications performed two or four times a year. Scand J Dent Res, 1990; 98: Warren U, Levy SS, et al. Prevalence of Dental Fluorosis in the Primary Dentition. J Public Health Dent 2001; 6: ADDITIONAL RESOURCES 1. The Handbook Pediatric Dentistry; Nowak, A. Chicago, American Academy of Pediatric Dentistry. 1999, pp Guidelines for Fluoride Therapy. American Academy Pediatric Dentistry, Pediatr Dent. 2001; 23 (Reference Manual) p Schachtele CF, Jensen ME. Can foods be ranked according to their cariogenic potential? In, Guggenheim B (ed): Cariology Today. Basel, Karger, 1984, pp

63 4. Recommendations for using fluoride to prevent and control dental caries in the United States. MMWR. 2001; 50(RR14): Featherstone JDB. Prevention and reversal of dental caries: role of low level fluoride. Community Dental Oral Epidemiol 1999; 27:

64 VI. NUTRITIVE AND NON-NUTRITIVE SUCKING Learning Objectives At the conclusion of this section the reader should be able to: 1. Differentiate between nutritive and non-nutritive sucking. 2. Describe the prevalence of non-nutritive sucking. 3. Explain the non-dental effects of non-nutritive sucking. 4. Describe the dental effects of non-nutritive sucking. 5. Discuss possible interventions for prolonged non-nutritive sucking. 6. Understand bruxism in pediatric patients. Sucking Reflex/Habits The biological and inherent drive to suck by infants is a normal physiological and psychological behavior seen in all infants. When performed by an infant/toddler and no nutrition is obtained it is referred to as non-nutritive sucking (NNS). In those instances it is satisfying a psychological need and not a physiological need. When rewarded NNS can lead to a learned habit. The prevalence of NNS has been reported widely in the literature to be around 70-90% of the children studied. Other studies report almost 100% of all infants perform NNS habits in their early years. 2 Reports show a wide distribution of the ages when NNS is discontinued. Generally with increasing age NNS decreases; pacifiers before digits. Overall the majority of toddlers discontinue between 2-4 years of age. Nowak, et al 1 reported that between months, over 50% of the subjects followed discontinued NNS; with 71% by 36 months and 90% by 64

65 48 months. Factors associated with prolonged sucking habits are older maternal age, higher maternal education and no older siblings 3. Non Dental Effects of NNS Behavior Pacifier use has been reported to be associated with a number of non-oral conditions. Those conditions include: increased risk for otitis media; early cessation of breast-feeding; shorter duration of breast feeding; reducing the occurrence of sudden infant death (SIDS); reduction in crying; and increase in pacification/calming. Digit sucking has not been reported to be associated with any of the above non-oral conditions. Dental Effects of NNS Behavior Although there are numerous reports on the effects of NNS and oral development, most have been retrospectively and cross sectionally studied and not prospective longitudinal studies. To study NNS effects, one must consider the frequency (how often), duration (how long), and the intensity (how strong) of the sucking behavior. When observing infants and toddlers there is a wide variation in the NNS activity. So it is of little value to ask the caretaker if the child uses a pacifier or sucks a digit without determining the daily frequency and intensity. NNS can have effects on both the primary and permanent dentitions (alignment of teeth) and the occlusion (bite). The most common problems reported are (Table VI-1) 65

66 Possible Oral Effects of Prolonged Non-Nutritive Sucking Maxillary Incisor proclination Increased overjet Open bite Posterior Crossbite Decreased palatal width Decreased maxillary intercanine width Mandibular arch retrusion Table VI-1 a. open bite (space between upper and lower front teeth when the back teeth are biting together) b. excessive overjet anterior posterior space between upper and lower anterior teeth c. posterior crossbite narrow upper arch that does not allow proper closure with lower arch. Because a digit NNS behavior is more difficult to intervene than a pacifier habit, clinical reports suggest more severe dental effects. It appears that the pressures caused by the digits are more concentrated on individual teeth and the two arches and therefore can cause a greater effect. A properly designed pacifier with a curved shield that fits comfortably under the nose helps to distribute the pressure created in sucking over a broad area and may decrease the dental effects while satisfying the infant s sucking needs. 66

67 Interventions and Recommendations Based on the literature: 1. NNS is a normal activity for infants. 2. NNS has been reported to be associated with non-oral conditions. 3. Majority of infants/toddlers will discontinue NNS shortly after their second birthday. 4. Prolonged NNS can effect alignment of teeth and bite relationships. Therefore it is recommended that: 1. During prenatal classes, expected parents be advised on both the positive and negative outcomes associated with NNS and appropriate time for discontinuation. 2. Once the infant is born NNS behavior should be reviewed with the parent. If a pacifier is selected by the parents recommendations should include the cleanliness of the pacifier; to only purchase a pacifier that meets the standards of the US consumer Product Safety Commission; never place honey, sugar or any sweet syrup on the nipple to encourage sucking and to decrease the risk of cavities. 3. Replace the pacifier periodically when the nipple is worn or cracked and move to a size most appropriate for the age of the infant. 4. Caution parents on early discontinuation and remind them that most toddlers will stop NNS after their second birthday. 5. If the habit persists into the fourth year the pediatric dentist should consider intervention for a change in behavior. If a dental home is established around one year of age the pediatric dentist will monitor NNS behavior and provide anticipatory guidance information as to the continuation of the behavior and appropriate time for intervention. The non-dental health professional should 67

68 encourage the parent to comply with the pediatric dentists recommendation and reinforce a parent s positive activity. Bruxism Bruxism is the grinding of teeth, which usually occurs with sleep but can occur in children with special health care needs while awake. Reports as high as 20-25% of all children brux. Some parents report irritating noises from children who brux that can be heard long distances (from the child s bedroom to the family room with the doors closed). 4 Pediatric bruxing has not been widely studied. Most clinical observations report that it is self-limitating and decreases with age and very seldom has a dental effect, although there has been isolated reports of attrition of the primary teeth. Children with a neurological diagnosis seem to report a higher prevalence of bruxing but no studies have followed the condition on a longitudinal basis. Presently there is no single recommended intervention for bruxing. References 1. Nowak A, Warren J, Levy S, Slayton S. Discontinuation of Non-nutritive sucking. J Dent Res, 1997; 76:# Nowak A and Warren J. Infant oral health and oral habits. Ped Clin NA, 2000; 47: Warren J, Levy S, Nowak A, Tang S. Non-nutritive sucking behaviors in pre-school children: a longitudinal study. Pediatr Dent, 2000; 22: Weideman CL, Bush DL, Yan-Go Fl, et al. Incidence of parasomnias in child bruxers versus nonbruxers. Pediatr Dent, 1996; 18: Additional Resources 68

69 1. Vanderas AP and Manetas KJ. Relationship between malocclusion and bruxism in children and adolescents. Pediatr Dent, 1995; 17: Larsson E. Dummy and finger sucking habits with special attention to their significance for facial growth and occlusion. Swed Dent J. 1972; 65: Larrson E. The Effect of dummy sucking on the occlusion: a review. Europ J Orthod 1986; 8:

70 VII. ORAL TRAUMA PRIMARY DENTITION Learning Objectives At the conclusion of this section the reader should be able to: 1. Describe the prevalence of oral/dental trauma in infants and toddlers. 2. Discuss the possible long-term effects of oral trauma. 3. Understand the importance of intervention following a traumatic event. 4. Recommend emergency intervention or immediate referral to a pediatric dentist for management (when indicated). 5. Discuss the possible oral/dental manifestations of child abuse. EPIDEMIOLOGY Infants and toddlers will fall when crawling or walking, tumble off a toy or bump into furniture or a wall when running. Fortunately a few tears and a hug is all that is required and life goes on. But sometimes injuries occur and oral injuries are quite upsetting to caretakers. What to do and where to go are a real problem especially if a Dental Home has not been established. Most community hospitals do not have dental attendings available for immediate referral and intervention. Most national statistics report on face and head injuries secondary to trauma and seldom report dental and oral manifestations. Very few infants escape the transition to being a toddler without a bruised lip, a torn frenum and a bumped tooth. Peak periods for trauma are between months; with more males involved after 12 months of age. Although reported earlier there now appears to be no seasonal variations in oral trauma. No longer are activities limited because of weather with a number of venues available for year long fun and games. 70

71 The teeth most often affected are the maxillary anterior primary teeth. Although fractured crowns are reported more often the most common injury to primary teeth is a luxation or displacement injury with gingival hemorrhage. These injuries are most likely due to the direction of the force and the elasticity of the alveolar bone surrounding the primary teeth. Intrusion injuries are often seen where usually one primary tooth is driven into the alveolar bone because of the force. Avulsion of a tooth can also occur and aspiration of the displaced tooth must be considered. 1,2 (Figure VII-1) Trauma Primary Teeth Figure VII-1 With permanent teeth, crown fractures are more common and can involve only a small portion of the crown or the entire crown with pulpal involvement. Root fractures are also possible and depending where the fracture is located on the crown or if it is a horizontal or a vertical fracture the outcomes differ greatly. Besides teeth all soft tissues of the oral cavity can be involved including lips, tongue, palate, frena and gingival. Occasionally impalement injuries occur when a toddler falls with an object in the mouth and penetrates the soft tissues, especially the muco-buccal folds or the soft palate. 71

72 Jaw fractures are not common in infants and toddlers. Nevertheless a fracture does need to be ruled out especially with a significant blow to the face or chin, with difficulty in closing the jaws, limited occlusal opening, facial asymmetry or paresthesia. INTERVENTION AND EMERGENCY MANAGEMENT All injuries to the mouth and teeth are important and should be assessed as soon as possible to document the initial findings, provide emergency treatments and arrange a schedule of monitoring and follow up. Non-dental health professionals will be called upon for assistance especially during the younger years when a parent has not yet established a Dental Home. In a study only 17% of pediatricians felt confident in managing dental trauma. 4 There are no studies reporting on other health professionals and their training and managing dental emergencies. Once it has been assessed that the ABC s of medical emergencies have been fulfilled and no medical problem exists, the teeth and mouth should be evaluated. Facial bones should be palpated; and lacerations, bruises and swellings noted; opening and closing of the mouth attempted; lateral excursions of the jaw attempted. Teeth should be viewed for missing, or fractured crowns, and mobility or intrusion. Intraoral soft tissues should be checked for bruising and lacerations. Trauma can be associated with an accident and for legal reasons extraoral and intraoral photographs should be made. Depending on the findings, the age of the patient, anticipated behavior and location of the examination, radiographs may be ordered. Most ED in community hospitals do not have radiographic units to make intraoral radiographs. A consult/referral to the pediatric dentist should be considered. Because facial and oral injuries are reported in suspected child abuse, it is mandatory that examining health professionals evaluate the mouth and report or rule out oral injuries. 72

73 The non-dental health professional has limited ability to diagnose and treat oral trauma. It will be important for them to rule out medical emergencies, assess the needs for tetanus booster, and to make the appropriate referral for treatment and/or follow-up. Contemporary literature does not recommend reinserting an avulsed primary tooth. But an avulsed permanent tooth needs to be replanted quickly with appropriate splinting and follow-up by a dentist. 1 Depending on the tooth and the extent of crown fractures, emergency management is important to protect the pulp from invading bacteria. If possible an intermediate, esthetic pleasing repair of the crown should be placed to avoid the psychological trauma of the fractured tooth. Radiographs are indicated to determine the status of the roots, the alveolar bone, location of intruded teeth in relationship to unerupted permanent teeth, location of the crown fracture in proximity to the pulp and finally any alveolar bone or condular fractures. Outcomes are not always predictable but can be improved with appropriate and early evaluation diagnosis and intervention. Soft tissue damage when managed properly will usually heal without incidence. Facial lacerations should be managed by the plastic surgeon to avoid scarring. A most common consequence of primary tooth trauma is a dark tooth. Colors vary from yellow, gray, brown, pink or any combination. Discoloration is due to damage to the pulp, its blood supply and tissue ischemia. Monitoring is indicated and unless an abscess develops seldom is treatment provided. (Figure VII-2) 73

74 Trauma Consequences Figure VII-2 Intruded primary tooth may reerupt but could take up to six months. A possible sequela is ankylosis where the tooth and bone join preventing eruption. Early loss of a primary tooth may lead to tongue habit formation. No reports suggest speech problems. With multiple loss of teeth and a severe non-nutritive sucking habit, the risk of arch width loss increases with possible irregularities in the bite. A very early intruded primary tooth can affect the developing permanent dentition. Depending on the stage of development, the permanent tooth could erupt with a hypoplastic enamel surface or a hypocalcified surface. Permanent tooth trauma has many more severe long-term consequences and are usually under the supervision of a pediatric dentist and will not be discussed here. The only situation that may involve the primary care medical provider would be the avulsion of a permanent tooth. If the parents or school nurse calls and inquires what to do the following should be recommended: 3 1. Find the avulsed tooth. 2. Hold it only by the crown. 3. Wash it off under cold water; do not scrub 4. Place it back into the socket quickly. If not possible to reinsert, place it in cold milk or water and transport both child and tooth to the dentist. Another 74

75 useful product to have in schools would be the Save-a-Tooth preserving system. Save-A-Tooth Refer to a pediatric dentist for further evaluation, radiographs and treatment. INJURY PREVENTION During anticipatory guidance sessions, caregivers should be advised on how to make a home injury proof. But no matter what is done, more than likely an infant/toddler will someday suffer a traumatic event that could also involve the face and mouth. Having a dental home for the caregiver to contact immediately will probably be the most important recommendation you can make as the primary care provider. With increasing age, caregivers should be encouraged to purchase appropriate size helmets for the children to use when on tricycles and bicycles, scooters, and other wheeled toys. Although contact sports are being introduced at earlier ages, there are no guidelines presently that suggest a preschooler should have a mouthguard. As the child ages and the sports get rougher, mouthguards should be recommended. Custom fitted are the best but with the dentition changing frequency between six and fourteen years of age, it is difficult to maintain a stable fit with the loss of the baby teeth and the erupting permanent teeth. CHILD ABUSE As a final reminder, oral and facial sites are frequently reported in child abuse cases. Probably the most common and a SCAN characteristic is the torn maxillary frena. Others would be bite marks on the neck, ears, and face. In addition, the red impression of the fingers on the cheeks after a slap are at least questionable signs of abuse and should be investigated. REFERENCES 1. Andreasen JO. Injuries to developing teeth, in Andreasen JO and Andreasen FM. Injuries to Teeth 3 rd ed. Copenhagen: Munksgaard Publishers, 1993;

76 2. Harding A and Camp J. Traumatic injuries in the pre-school child. Dent Clin NA, 1995; 39: Krasner P and Rankow H. New philosophy for the treatment of avulsed teeth. Oral Surg, Oral Med, Oral Pathol, Oral Radiol Endod, 1995; 79: Tsamtsouris A and Gavsis V. Survey of pediatricians attitudes towards pediatric dental health. J Pedodon, 1990; 14: ADDITIONAL READINGS 1. Andreasen JO and Andreasen FM. Traumatic dental injuries a manual. Copenhagen, Munksgaard Publishers, Committee on Child Abuse and Neglect. Oral and Dental Aspects of Child Abuse and neglect, Pediatrics, 1999; 104: Diab N, Mourino AP. Parental attitudes towards mouthguards. Pediatr Dent, 1997; 19: Lee JY, Vann WF et al. Management of avulsed permanent incisors: a decision analysis based on changing concepts. Pediatr Dent; 2001:23: McTigue DJ. Diagnosis and management of dental injuries in children. Ped Clin NA, 2000; 47: Trauma, in The Handbook Pediatric Dentistry, 2 nd ed. Nowak, AJ editor, Chicago, American Academy of Pediatric Dentistry, 1999; pp

77 7. Guidelines for the Management of Acute Dental Trauma AAPD. Pediatr Dent. Reference Manual, ; 23: Guidelines on Oral and Dental aspects of Child Abuse and Neglect - AAPD. Pediatr Dent. Reference Manual, ; 22:

78 VIII. CHILDREN WITH SPECIAL HEALTH CARE NEEDS Learning Objectives At the conclusion of this section the reader should: 1. Understand the increased risk factors for oral disease in children with special health care needs (CSHCN) 2. Be able to describe general oral health recommendations for CSHCN 3. Be familiar with oral management strategies for specific medical diagnoses. Introduction Addressing the oral health needs of children with special health care needs (CSHCN) is made difficult because of the lack of national reports on the prevalence of oral disease in this population. Numerous studies are available that report on oral disease prevalence but generally the subjects examined were a small subset of a CSHCN population. In addition the anecdotal reports in the literature usually report on a practitioners or clinics experiences. Are these patients truly representative of the CSHCN population or are they the exception because they have dental disease and a parent/caregiver who sought dental care? How about all the other CSHCN who do not have routine professional dental supervision? Newacheck, et al 2 reports that one of the most prevalent unmet health care needs of CSHCN is dental care. Too often there are delays in scheduling early professional examination and supervision because of the large number of other health related, educational, social and behavioral issues that are being assessed and treatment planned. Because of the limited availability of dentists trained and willing to follow CSHCN, financial reimbursement, and caregivers apprehension, it is not unusual for CSHCN not to have a dental home until an oral problem presents as affecting general health. 78

79 It is not the intent of this section to review all of the diagnoses that are represented in the CSHCN populations. Rather to present a general review of the role that a non-dental health professional has in assisting in oral health care and networking with a receptive dental community. General Oral Health Information 1. Oral diseases affect CSHCN in the same manner as in all children. Its progress and severity may be enhanced because of the medical diagnosis, the medical interventions, and the pharmaceuticals prescribed. 2. Early professional examination and intervention is as important in CSHCN as in all children. There is no reason to delay scheduling the initial examination because the child has a medical diagnosis. 3. Preventive daily home care should be initiated as soon as the first tooth erupts. 4. Optimal use of fluorides both systemic and topical should be initiated as soon as appropriate based on the published AAP, ADA, AAPD Guidelines. (see Section V) 5. A Dental Home is very important for CSHCN to eliminate delays for necessary treatment in case of oral trauma, spontaneous oral infection or to respond to a caretaker s questions. 6. If the CSHCN is at high risk for oral diseases, more frequent professional supervision may be necessary than the usual once or twice a year. 7. Dental practitioners may have specific scheduling requirements for routine visits for CSHCN to facilitate treatment during times when the patient, the doctor and the staff are at optimal conditions to receive and provide treatments. 8. Dental treatments may require additional time to account for the patient s medical diagnosis, medications, behavior, and complexity of the treatment. 9. Alternative treatments may be indicated because of the patient s medical diagnosis, anticipated behavior, and severity of the oral disease, quality of life and anticipated patient longevity. 79

80 10. Dental treatments can be facilitated when indicated with the use of partial or complete medical immobilization of the patient. Immobilization may be performed by parents, dentists, or staff. Commercial stabilizing systems may be preferred over human immobilization. 11. Pharmaceutical support may be necessary to optimally treat the CSHCN when indicated. This may involve oral or injectable pharmaceuticals. In some cases a general anesthetic is the technique of choice. 12. Even though a CSHCN may be enrolled in a specialty team clinic, for example a child development clinic, do not assume that the child is receiving comprehensive preventive oral health care. Parents and caregivers should be questioned to identify the child s primary dental care provider. This should be a pediatric dentist or a family dentist who has been trained to care for CSHCN. If none identified a recommendation should be provided. Specific Oral Health Information (selected) 1. Children with a craniofacial diagnosis These children will be identified early and will most likely be followed by a craniofacial multidisciplinary team. Unfortunately there will be teams that provide specialty oral care (oral surgery, orthodontics and prosthodontics) but not primary care. Confirm that a pediatric dentist or general dentist is available to provide comprehensive, periodic, preventive and rehabilitative oral health care. 2. Children with a genetic disorder Some genetic diagnoses will primarily affect the teeth and mouth, (For example dentinogenesis imperfecta) while others may have numerous manifestations including oral (ectodermal dysplasias). 80

81 These children may also be followed by a specialty multidisciplinary team. If so, primary oral health supervision is indicated for the monitoring of growth and development and the scheduling of treatment when appropriate. Waiting until the child is older is inappropriate management. Immediate referral to a dental practitioner trained in the management of CSHCN is indicated. 3. Hematological disorders Children with the diagnosis of anemias, clotting factor deficiency, thrombocytopenias and platelet dysfunctions, will require medical management in coordination with oral health supervision and treatment. Early consultation with a pediatric dentist is indicated for comprehensive preventive management to reduce or prevent dental infections. With appropriate and coordinated medical management dental treatments are not contraindicated. 4. Cardiovascular diseases Children with a cardiovascular problem will most often be diagnosed early and followed by a specialty team. Too often routine preventive oral management is delayed until a crisis develops. Early referral and oral health management is indicated to reduce or eliminate dental infections. With appropriate and coordinated medical management all necessary dental treatments are indicated. 5. Neurological disorders Children diagnosed with a neurological disorder (for example a seizure disorder) require early and periodic oral management. In addition to routine oral problems, these children may be prone to oral trauma and oral manifestations secondary to medical management (for example gingival 81

82 overgrowth secondary to Dilantin). Some may require antibiotic considerations prior to dental treatments because of shunts. 6. Infectious diseases Children with HIV diagnoses may have oral manifestations and require oral health management and special handling. 7. Cancer diagnosis Depending on the type of cancer and the medical management there may be direct oral manifestations (gingival hemorrhage secondary to reduced platelets) or indirect manifestations secondary to medical management (chemo and radiation therapy). In all diagnoses, immediate consultation should be made for an oral evaluation followed by appropriate oral management and monitoring. 8. Developmental disabilities These children will be at risk for oral disease as with all other children but severity will be dependent on a number of management factors. Because of additional risk factors early examination and optimal preventive management are indicated. Severity of the disability will determine management by the dentist. Frequent preventive maintenance, optimal fluoride applications and thorough home oral care by parents and caregivers are most important. 9. Asthma Diagnoses There are no direct oral health manifestations associated with asthma. But because of the diagnosis children may be at a heightened risk for oral diseases and also management in the dental office because of a hyperactive 82

83 airway. Medical management and consultation before a dental appointment is warranted especially if the patient is using corticosteroid medications. 10. Organ and marrow transplants All transplant patients are at increased risk for oral related problems. Ideally all should have a baseline examination prior to medical intervention. Optimal oral health is required to decrease morbidity and mortality due to infections. Chemo and radiation therapy can have direct effects on the oral tissues and in the youngest patients on the developing dentition. Maintenance drugs may also have oral affects, e.g. decreased saliva and gingival overgrowth. Guidelines for oral health care are published. 1 REFERENCES 1. Guidelines for the management of Pediatric Dental Patients Receiving Chemotherapy, Bone Marrow Transplantation and/or Radiation Pediatr Dent. 2001; 23 (Reference manual) p Newacheck PW, McManus M, Fox HB, et al. Access to Health Care for Children with Special Health Care Needs. Pediatrics 2000; 105: ADDITIONAL RESOURCES 1. Acs G and Cozzi E. Antibiotic prophylaxis for patients with hydrocephalus shunts: a survey. 1992; 14: Canady JW, Thompson SA et al. Oral commissure burns in children. Plast Reconstr Surg, 1996; 97: Chigurupati R, Raghavan S., et al. Pediatric HIV infection and its oral manifestations: a review. Pediatr Dent, 1996; 18:

84 4. Cleary M, Francis D., et al. Oral health implications in children with inborn errors of intermediary metabolism: a review. Inter J Paediatr Dent, 1997; 7: Dahms WT. An update in diabetes mellitus. Pediatr Dent, 1991; 13: Dunn N, Russell EC and Maurea HM. An update in pediatric oncology. Pediatr Dent, 1990; 12: Dyment HA and Casas MJ. Dental care for children fed by tube: a critical review. SCD Special Care in Dent, 1999; 19: Fernald GW, Roberts MW, Boat TF. Cystic fibrosis: a current review. Pediatr Dent, 1990; 12: Hallett KB, Radford DJ et al. Oral health of children with congenital cardiac disease: a controlled study. Pediatr Dent, 1992; 14: Hennequin M, Faulks D, Veyrune JL, et al. Significance of oral health in persons with Down Syndrome: a literature review. Develop Med and Child Neuro 1999; 41: Isman B, Newton R et al. Planning Guide for Dental Professionals Serving Children with Special Health Care Needs. University of Southern California Affiliated Program, Children s Hospital, Los Angeles, Kilpatrick NM, Awang H. et al. The implications of phenylketonwia on oral health, 1999; 21: Klein U, Nowak AJ. Characteristics of patients with autistic disorder presenting for dental treatment. SCD Special Care Dent, 1999; La Fonseca MA. Long term oral and craniofacial complications following pediatric bone marrow transplantation. Pediatr Dent, 2000; 22:

85 15. Mathew T, Casamassimo P, Wilson S et al., Effect on dental treatment on the lung function of children with asthma. JADA, 1998; 129: Moore PA, Orehard T. et al. Diabetes and Oral Health Promotion. JADA, 2000; 131: Nelson LP, Voreles SD and Holmes G. An update in pediatric seizure disorders. Pediatr Dent, 1991; 13: Pope JEC, Curzon MEJ. The dental status of cerebral palsied children. Pediatr Dent 1991; 13: Sams DR, Thorton JB et al. Managing the dental patient with sickle cell anemia: a review. Pediatr Dent, 1990; 12: Seymour RA, Thomsson JM. Risk factors for drug induced gingival overgrowth. J Clin Periodontol 2000; 27: Shecky EC, Healon N. et al. Dental management of children undergoing liver transplantation. Pediatr Dent, 1999; 21: Slavkin HC. The Surgeon General s Report and Special Needs Patients: a framework for action for children and their caregivers. SCD Special Care in Dent: 2001; 21: Werner CW and Saad T. Prophylactic antibiotic therapy prior to dental treatment for patients with end-stage renal disease. SCD Special Care Dent, 1999; 19:

86 IX. ADDITIONAL TOPICS Learning Objectives At the conclusion of this section the reader should: 1. Understand the increased risk of oral disease in adolescent patients. 2. Understand the common occlusal and alignment irregularities that can be associated with the primary and early mixed dentitions. 3. Recognize the need for oral protection when participating in contact sports. 4. Discuss the importance of a healthy and bright smile. 5. Understand the prescribing of dental radiographs in children. 6. Recognize the need for a variety of behavior management techniques for dental treatment. A. The Adolescent Patient The adolescent patient should enjoy optimal oral health, especially if during the early years they had been routinely followed for comprehensive preventive oral health care. The majority of adolescent patients who have followed a periodic comprehensive recall schedule will be caries free. Unfortunately this is not always the case and some adolescents will demonstrate severe dental disease including cavities, gingival disease and malocclusion. All epidemiological studies show that from the preschool years through high school the caries rate continues to rise 2. Interestingly just over half (50.7%) of year olds had a dental visit in 1996 compared to 55.2% of 6-10 year olds. Of concern is that only 31.7% of non-whites, 35.8% of low income and 29.3% of year olds had dental services in

87 New at-risk behaviors begin during this period. These include use of alcohol, spit and smoke tobacco, recreational and sports enhancing drugs, intraoral and perioral piercing and sexual experimentation. Teenage pregnancies present unique management considerations and require special attention. 4 With changing dietary patterns, increased social and athletic activities and decreases in personal hygiene practices, it is no wonder that adolescent patients can be at increased risk for oral diseases. Although the social, behavior and physiological factors affecting adolescents are great, personal experiences suggest that a highly cariogenic diet, together with a negative attitude with personal hygiene and self esteem are risk factors most associated with poor oral health in adolescents. So it is important for non-dental health practitioner to include in their anticipatory guidance information on practices that will promote oral health. Dietary practices will be the most challenging to intercept. Snacking and drinking cariogenic beverages need to be addressed in a positive manner. Most mouths cannot tolerate frequent bathing by sweetened beverages and high carbohydrate content snacks day after day after day. The preventive activities to emphasize are: 1. Daily brushing with fluoridated toothpaste. 2. Balanced nutritious diet with moderate consumption of sweetened beverages and snacks. 3. Periodic visits to the pediatric dentist or family dentist for preventive maintenance. 4. Recommend occlusal sealants as soon as permanent molars erupt. Other teeth and surfaces at-risk for cavities may require sealants. 87

88 5. Practice flossing at least a few times a week, progressing to nightly flossing after brushing. 6. Consider using fluoride rinses if told that teeth are showing early signs of decalcification. B. Orthodontic Interventions Many patients will demonstrate some degree of irregularities with alignment of their teeth and the relationship of their jaws to each other. Whether treatment is necessary will depend on a number of factors but function and oral health should be the ultimate reasons. With periodic monitoring by the pediatric dentist, intervention can be recommended and scheduled at appropriate times. Preventive or interceptive orthodontic treatments are recommendations that may be appropriate in the primary or early mixed dentitions. Sometimes they can correct a developing problem or reduce the complexity of more definitive treatment after the permanent teeth have erupted. Early treatment versus late treatment for malocclusions has been debated for some time. Both have advantages and disadvantages. Parents should request second opinions before initiating a plan of treatment. 6 With techniques available today most treatments can be pleasant and without discomfort. Nevertheless compliance is necessary and some children are not prepared at an early age to begin treatment and the necessary home care. Oral hygiene is most important as well as dietary modifications. Common problems that can be intercepted or treated early. 88

89 1. Delayed exfoliation of primary teeth most commonly the mandibular anterior incisors may erupt without the loss of the primary tooth. This is often described as a second row of teeth. Intervention is most appropriate. (Figure IX-1) Mandibular anterior teeth Delayed exfoliation Figure IX-1 2. Anterior crossbite usually observed when the permanent maxillary anterior teeth are erupting and will erupt behind the lower anterior teeth. Interception is most appropriate and is usually accomplished without difficulty if observed early and treatment initiated. (Figure IX-2) 89

90 Anterior cross bite Figure IX-2 3. Posterior crossbite may be observed by the parents but most likely will be reported by the dentist. In this condition the width of the upper jaw is reduced so that the jaws upon closure are asymmetric with a shift of the mandible to either side. When observed upon closing the face may also be asymmetric. Expansion of the upper jaw is indicated to allow both jaws to meet normally on closure. (Figure IX-3) Posterior crossbite with Mandibular shift Figure IX-3 4. Ectopic eruption of molars this will be reported by dentists by stating that one or two molars (usually first 90

91 permanent molars) are not erupting. A radiograph will show that an edge of the erupting molar is wedged against the adjacent primary molar. Early intervention is appropriate. (Figure IX 4) Ectopic Eruption Of Permanent molar Pre-treatment Treatment Post- treatment Figure IX-4 5. Loss of primary molar prematurely whatever the reason may be the space needs to be preserved for the eruption of the permanent tooth. Space maintainers are appropriate to be placed to preserve the space. (Figure IX-5) 91

92 Space Maintainer Primary Dentition Figure IX-5 6. Habit appliances with prolonged digit/thumb habits, intervention is indicated to stop the habits. There are many interventions that are available that include rewards, counseling, and behavior modification. If they fail, an appliance (fixed or removable) can be fabricated for assisting and stopping the habit along with behavior modification. Opinions vary among practitioners and parents of the type of appliance to use. Whatever is used the child must comply and be rewarded for positive behavior. C. Sports and Oral Health Two issues related to sports for pediatric patients are protecting the teeth against injury and the use of sports drinks. Mouthguards are indicated for use during contact sports. 1 A custom made well fitted guard is ideal for comfort and protection. Unfortunately, from around 6 through 12 to 14 years old the dentition is going through a series of transitions that make fabrication of a custom guard difficult. An alternative are stock and self-adapted 92

93 trays. Although not ideal and usually not as comfortable, they do offer protection until a custom guard can be fabricated. Sports drinks are commonly promoted and have become the drink of young athletes as well as many others. 3 Sports drinks have ingredients that can be cariogenic as well as erosive to enamel. The actual effect is controversial and at this time in United States there seems to be no agreement on the effect of sports drinks on oral health. Nevertheless it is important to know that erosion and decay are the result of two different processes. Decay is the result of an infection and the other (erosion) the result of a chemical response. In the presence of an at-risk child with an unclean mouth and a cariogenic diet, sports drinks will only add to the risk factors. It is difficult to defend the use of sports drinks in young children and appropriate alternatives should be recommended by health practitioners. D. Bright Smiles A bright and wide smile is the look many adolescents want. Whitening (bleaching) of teeth has become very popular and reported in the press, TV and radio. Kits are sold in drug stores and professional whitening is recommended in dental offices. If used appropriately bleaching can be safe and effective. Surface staining needs to be professionally removed before chemical bleaching of teeth begins. Teeth that have congenital pits and discoloration will not be good candidates for bleaching. In addition teeth heavily stained (intrinsically) because of medications taken during enamel formation will require more than bleaching. Very thin tooth colored plastic veneers can be bonded to the surface of these teeth. 93

94 For all these reasons the pediatric dentists should be consulted and the advantages and disadvantages of bleaching techniques discussed. E. USE OF DENTAL RADIOGRAPHS IN PEDIATRIC PATIENTS Radiographs are essential for providing additional information to clinical examinations, assessing oro-facial growth and development, evaluating teeth and facial bones following trauma, and monitoring dental treatments. When ordered properly, following contemporary techniques with modern equipment and body shielding aprons and neck collars, radiation exposure can be minimized. Guidelines have been developed by a Federal consensus panel and the American Academy of Pediatric Dentistry. They are based on the dental developmental status of the child, the type of examination, risk for disease and positive historical findings. (See Appendix) The guidelines are recommendations for dental practitioners to use and are subject to clinical judgment, patients health history and completing a clinical examination. F. MANAGING THE BEHAVIOR OF A PEDIATRIC DENTAL PATIENT Many children fear medical and dental appointments and respond in a variety of behaviors. Some behavior is age appropriate the child is just too young to understand or follow instructions. Others are determined by the childs physical, intellectual, emotional and social development. Still others are due from fears transmitted from 94

95 parents, previous unpleasant experiences, inadequate preparation and dysfunctional parenting practices. Fortunately the pediatric dentist has available a variety of behavior management approaches. Once the child is evaluated and the parent is consulted as to the dental treatment needs, a plan to manage the behavior is discussed. Approaches vary from one child to the next and from one practitioner to the next. REFERENCES Guidelines have been developed by the American Academy of Pediatric Dentistry that include both pharmacological and nonpharmacological approaches. (See Appendix) 1. Diab N and Mourino AP. Parental attitudes towards mouthguards. Pediatr Dent 1997; 19: Edelstein BL, Manski RJ et al. Pediatric Dental Visits during 1996: an analysis of the Federal Medical Expenditure Panel Survey. Pediatr Dent, 2000; 22: Murray B, Moss S. Sports drink and tooth decay. JADA, 1997; 128: Livingston HM, Dellinger TM et al. Considerations in the management of the pregnant patient. SCD Special Care Dent, 1998; 18: USDHHS. Oral Health in America: a report of the Surgeon General. Rockville, MD: US Dept HHS, NIDCR, NIH, 2000; pp Vig KWL, Fields HW. Facial growth and management of orthodontic problems. Ped Clin NA. 2000; 47: ADDITIONAL RESOURCES 95

96 1. The Selection of Patients for x-ray Examinations: Dental Radiographic Examinations. DHHS Pub FDA , October Guidelines for Prescribing Dental Radiographs. Pediatr Dent. 2001; 23 (Reference Manual): Guidelines for Behavior Management. Pediatr Dent. 2001; 23 (Reference Manual): Guidelines for the Elective use of Conscious Sedation, Deep Sedation and General Anesthesia in Pediatric Dental Patients. Pediatr Dent. 2001:23(Reference Manual): Policy Statement on Intraoral and Perioral Piercing American Academy of Pediatric Dentistry. Pediatr Dent. 2001:23(Reference Manual): Policy Statement on Prevention of Sports Related Injuries American Academy of Pediatric Dentistry. Pediatr Dent. 2001:23 (Reference Manual):36. 96

97 APPENDICES 1. Recommendations for Preventive Pediatric Dental Care (AAPD) Recommendations of Preventive Pediatric Care (AAP) Anticipatory Guidance for Pediatric Oral Health Guidelines for Prescribing Dental Radiographs (AAPD) Guidelines for Behavior Management (AAPD)

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