The condition of the
oral cavity is important to the physical and psychological health of every
child. School-aged children generally receive periodic dental examinations and treatment;
however, oral problems of infants frequently are recognized first by the
physician.
All parents of
children should receive oral health counseling that includes anticipatory
guidance, oral hygiene instruction, and diet counseling. Children identified at
high risk for dental disease (e.g., low socioeconomic setting, inappropriate
feeding habits) should be referred for dental care by age one, and periodic
dental examinations as frequently at every 3 mo. It is recommended that most
children should have periodic dental examinations at six month intervals;
however, some children at low risk can be seen yearly.
The times of eruption
of the primary and permanent teeth are listed below
|
|
|
Tooth |
First
evidence of
calcification |
Eruption |
|
|
Max. |
Central incisor Lateral incisor Canine First molar Second molar |
3-4 mos. in
utero 4 1/2 mos. in utero 5 1/2 mos. in utero 5 mos. in
utero 6 mos. in utero |
7 1/2 mos. 8 mos. 16-20 mos. 12-16 mos. 20-30 mos. |
|
Primary dentition |
|
|
|
|
|
|
Mand. |
Central incisor Lateral incisor Canine First molar Second molar |
4 1/2 mos. in utero 4 1/2 mos. in utero 5 mos. in utero 5 mos. in utero 6 mos. in utero |
6 1/2 mos. 7 mos. 16-20 mos. 12-16 mos. 20-30 mos. |
|
|
|
|
|
|
|
|
Max. |
Central incisor Lateral incisor Canine First premolar Second premolar First molar Second molar Third molar |
3-4 mos. 10 mos. 4-5 mos. 1 1/2-1 3/4 yrs. 2-2 1/4 yrs. At birth 2 1/2-3 yrs. 7-9 yrs. |
7 - 8 yrs. 8 - 9 yrs. 11-12 yrs. 10-11 yrs. 10-12 yrs. 6 - 7 yrs. 12-13 yrs. 17-21 yrs. |
|
Permanent dentition |
|
|
|
|
|
|
Mand. |
Central incisor Lateral incisor Canine First premolar Second
premolar First molar Second molar Third molar |
3-4 mos. 3-4 mos. 4-5 mos. 1 3/4-2 yrs. 2 1/4-2 1/2 yrs. At birth 2 1/2-3 yrs. 8-10 yrs. |
6 - 7 yrs. 7 - 8 yrs. 9-10 yrs. 10-12 yrs. 11-12 yrs. 6 - 7 yrs. 11-13 yrs. 17-21 yrs. |
Discrepancies in growth patterns are classified into
three main types of occlusion, determined when the jaws are closed and the
teeth are held together. In class I (normal) occlusion, the cusps of the posterior
mandibular teeth interdigitate ahead of and inside the corresponding cusps of
the opposing maxillary teeth. This relationship provides a normal facial
profile. In class II occlusion, “buck teeth”, the cusps of the posterior
mandibular teeth are behind and inside the corresponding cusps of the maxillary
teeth. This common occlusal disharmony is found in approximately 45% of the
population. The facial profile may give the appearance of a "receding
chin" (retrognathia) or protruding front teeth. The resultant increased
space between upper and lower anterior teeth encourages finger sucking and
tongue-thrust habits. Additionally, children with pronounced class II
occlusions are at greater risk of damage to the incisors due to trauma. In
class III occlusion, “underbite”, the cusps of the posterior mandibular teeth
interdigitate a tooth or more ahead of their opposing maxillary counterparts.
The anterior teeth appear in “cross-bite”, with the mandibular incisors
protruding beyond the maxillary incisors. The facial profile gives the
appearance of a "protruding chin" (prognathia).
Normally, the mandibular teeth are in a position just
inside the maxillary teeth, so that the outside mandibular cusps or incisal
edges meet the central portion of the opposing maxillary teeth. A reversal of
this relation is referred to as a cross-bite.
Cross bites may be anterior, involving the incisors; posterior, involving the
molars; or may involved single or multiple teeth.
If the posterior mandibular and maxillary teeth make
contact with each other but the anterior teeth are still apart, the condition
is called an open bite. Open bites
may be due to skeletal growth pattern or digit sucking. With prolonged digit
sucking, the open bite may not resolve. If mandibular anterior teeth occlude
inside the maxillary anterior teeth in an over-closed position, the condition
is referred to as a closed or deep bite.
Treatment of open and closed bites consists of orthodontic correction,
generally performed in the pre-teen or teenage years.
Overlap of incisors can result when the jaws are too
small or the teeth are too large for adequate alignment of the teeth. Growth of
the jaws is mostly in the posterior aspects of the mandible and maxilla, and therefore
inadequate space for the teeth at 7 or 8 years of age will not resolve with
growth of the jaws. Spacing in the primary dentition is normal and favorable
for adequate alignment of successor teeth.
Prolonged digit sucking can cause flaring of the maxillary
incisor teeth and an open bite. The prevalence of digit sucking decreases
steadily from the age of 2 years to approximately 10% by the age of 5. The
earlier the habit is discontinued after the eruption of the permanent maxillary
incisors (age 7–8), the greater the likelihood that there will be lessening of
the incisors flaring and bite opening. A variety of treatments have been
suggested, from behavioral modification to insertion of an appliance with
extensions that serves as a reminder when the child attempts to insert the
digit. The greatest likelihood of success occurs in cases in which the child
desires to stop. Stopping of the habit, however, will not rectify a
malocclusion caused by a deviant growth pattern.
The development of dental caries is dependent upon the
relationships among the tooth surface, dietary carbohydrates, and specific oral
bacteria. Organic acids produced by bacterial fermentation of dietary
carbohydrates reduce the pH of dental plaque adjacent to the tooth to a point
where demineralization occurs. The initial carious lesion appears as an opaque
white spot on the enamel, and, with progressive loss of tooth mineral,
cavitation occurs.
Current knowledge indicates that a group of microorganisms, mutans
streptococci, are associated with the development of dental caries on the
enamel surface. These bacteria have the
ability to adhere to enamel, produce abundant acid and survive at low pH. Demineralization
from acid production is determined more by the frequency of carbohydrate
consumption than by the actual quantity of carbohydrate eaten. For example,
cariogenic potential of a nursing bottle of apple juice that is consumed
throughout the night or at nap times, is much greater than that of the same
volume of apple juice consumed at a single meal. Additionally, sugar retained
orally for long periods (e.g., sucrose in sticky candies) is more cariogenic
than that in food products retained for short times.
Rampant caries in infants and toddlers, referred to as Early
Childhood Caries (ECC), Nursing Bottle Caries and Baby Bottle Tooth Decay, has
in the past been ascribed solely to inappropriate bottle feeding. While
the combination of a child being infected with cariogenic bacteria and the
frequent ingestion of sugar, either in the bottle or in solid foods, are
critical, other factors such as enamel hypoplasia of primary teeth due to
nutritional deficiencies during pregnancy or premature birth may play a role.
Reports have also associated “at will” breast feeding with caries of the
maxillary anterior teeth, but the possibility of cariogenic dietary practices
other than breast feeding, in such cases, needs further exploration.
If left untreated, dental caries usually destroy most of the tooth
and invade the dental pulp, leading to an inflammation of the pulp (pulpitis)
and significant pain. Pulpitis can progress to necrosis, with bacterial
invasion of the alveolar bone (dental abscess; periapical abscess). This
process may lead to sepsis and facial space infection. Such periapical
infection of a primary tooth also may disrupt normal development of the
successor permanent tooth.
Dental treatment can restore many teeth affected with dental
caries using silver amalgam or plastic restorations and crowns. If caries
involves the dental pulp, a partial removal of the pulp (pulpotomy) or complete
removal of the pulp (pulpectomy) may be required. If a tooth requires
extraction, a space maintainer to prevent migration of teeth may be indicated
to prevent impaction or malposition of permanent successor teeth.
Fluoride. The most effective preventive measure against dental caries is optimizing
the fluoride content of communal water supplies to one part per million. In
fluoride-deficient water supplies similar caries prevention benefits are
obtained from dietary fluoride supplements (see below table). The fluoride
level of a water supply can usually be obtained by calling the local public
health department. If a private water supply is used, it is necessary to get
the water tested for fluoride levels before fluoride supplements are
prescribed. To avoid potential overdoses, no fluoride prescription should be
written for more than a total of 120 mg of fluoride. Significant overdose of
fluoride (greater than 5 mg/kg) needs immediate medical attention. The use of
topical fluoride agents, applied professionally or by the patient, also are beneficial
to children at risk for caries.
Supplemental Fluoride Dosage Schedule
|
Fluoride
in Home Water (ppm) |
|||
|
Age |
<0.3 |
0.3–0.6 |
>0.6 |
|
6 mo.–3 yr. |
0.25* |
0 |
0 |
* mg fluoride per day
Oral Hygiene. Thorough daily brushing and flossing of the teeth may help
prevent dental caries and periodontal disease. Studies have shown that most
children under 8 years of age do not have the coordination required for
adequate oral hygiene. Accordingly, parents should assume responsibility for
the child’s oral hygiene, with the degree of parental involvement appropriate
to the child's changing abilities.
Diet. Decreasing the frequency of sugar ingestion prevents dental
caries. Therefore using sweetened beverages in the nursing bottle and bedtime
nursing bottles should be discouraged, and children at risk for dental caries
should reduce between-meal sugar containing snacks.
Dental Sealants. Plastic dental sealants have been shown to be effective in the
prevention of pit and fissure caries. Sealants are most effective when placed
soon after the teeth erupt (usually within 1–2 years) and when used in children
with deep grooves and fissures in the molar teeth.
GINGIVITIS. Poor oral hygiene results in the accumulation of a dental plaque
at the tooth-gingival interface that activates an inflammatory response,
expressed as localized or generalized reddening and swelling of the gingiva. In
severe cases the gingiva spontaneously bleeds and there is oral malodor. Treatment is with proper oral hygiene
(careful tooth brushing and flossing), and complete resolution can be expected.
TEETHING. Teething can lead to intermittent localized discomfort in the
area of erupting primary teeth, irritability, low-grade fevers and excessive
salivation; yet, many children have no apparent difficulties. Symtomatic treatment includes chewing on
ice rings and oral analgesics . Similar manifestations can also arise when the
first permanent molars erupt at about age 6.
Approximately 10% of children between 18 months and 18 years of
age will sustain significant tooth trauma. There appear to be three age periods
of greatest predilection: (1) toddlers (1–3 years), usually due to falls or child abuse; (2) school aged
(7–10 years), usually from bicycle and playground accidents; and (3)
adolescents (16–18 years), often the result of fights, athletic injuries, and
automobile accidents. Injuries to teeth are much more frequent among children
with protruding front teeth.. Children with craniofacial abnormalities or
neuromuscular deficits are also at increased risk for dental injury. Injuries
to teeth may involve the hard dental tissues, the dental pulp (nerve) and
injuries to the periodontal structure (surrounding bone and attachment
apparatus).
Fractures of teeth may be uncomplicated (confined to the hard
dental tissues) or complicated (involving the pulp). Exposure of the pulp will
result in its bacterial contamination, which can lead to infection and pulp
necrosis. Pulp exposure complicates therapy and may lower the likelihood of a
favorable outcome.
Trauma to the mouth most often affects the crowns or roots of the
maxillary incisor teeth. Uncomplicated crown fractures are treated by covering
exposed dentin and by placing an esthetic restoration. Complicated crown
fractures usually require endodontic (root canal) therapy. Crown-root fractures
and root fractures usually require extensive dental therapy. Such injuries in
the primary dentition may interfere with normal development of the permanent
dentition, and therefore, these types of injuries to the primary incisor teeth
usually are managed by extraction of the fractured segments.
Injuries resulting in fractured teeth should be referred to a
dentist as soon as possible. Furthermore, even when dentition appears intact
following oral trauma, the patient should be evaluated promptly by a dentist.
Baseline data (radiographs, mobility patterns, responses to specific stimuli
[percussion, electricity, hot, and cold]) enables the dentist to assess the
likelihood of future complications.
If a permanent tooth that has been knocked out is replanted within
20 minutes after injury, good success may be achieved; whereas if the delay
exceeds 2 hours, the failure (root resorption, ankylosis) is frequent. The
likelihood that normal reattachment will follow replantation of the tooth is
related to the viability of the periodontal ligament. Parents confronted with
this emergency situation should:
1. Find the tooth.
2. Rinse the tooth. (Do not scrub the tooth. Do not touch the root. After plugging the
sink drain, hold the tooth by the crown and rinse it under running tap water.)
3. Insert the tooth into the socket. (Gently
place it back into its normal position. Do not be concerned if the tooth
extrudes slightly. If the parent or child is too apprehensive for replantation
of the tooth, the tooth should be placed in cow's milk. Milk is transport
medium maintains periodontal ligament viability.)
4. Go directly to the dentist. (In transit,
the child should hold the tooth in place with a finger. The parent should
buckle a seatbelt around the child and drive safely.)
After the tooth is replanted, it must be immobilized (acrylic
splint) to facilitate reattachment; endodontic therapy is always required. The
initial signs of complications associated with replantation may appear as early
as 1 week post-trauma or as late as several years later. Close dental follow-up
is indicated for at least 1 year.
To minimize the likelihood of dental injuries:
1. Every child or
adolescent who engages in contact sports should wear a mouth guard, which may
be constructed by a dentist or purchased at any athletic goods store.
2. Helmets with
face guards should be worn by children or adolescents who are riding a bike,
skating, or using a skateboard.
Additionally, children with neuromuscular problems or seizure disorders
may need to use a helmet to protect the head and face during falls..
3. All children
or adolescents with protruding incisors should be evaluated by a pediatric
dentist or orthodontist.