Pediatric Dental Care and Dental Disorders

1. Pediatric Dental Care and Dental Disorders Hilary Suzawa Med/Peds December 2007

2. Common clinical questions and scenarios

3. When to kids usually get first tooth? • At birth, ~20 primary teeth are almost completely formed and hidden in the jawbones • Eruption of teeth highly variable • Four front teeth usually erupt first, beginning as early as 6 mths • Primary incisors 6-12 mths

4. Tooth Timeline • First molars at one year • Second molars at 2 yrs • Most children have a full set of primary teeth by age 3 years • Adult teeth begin to erupt at age 6 years • Lose primary teeth beginning age 6-7 years until ~12 years

5. “Tooth Mouse?” • Wikipedia on Tooth Fairy • “The most commonly accepted belief by academics is the fairy's development from the tooth mouse, depicted in an 18th centuryFrench languagefairy tale. In "La Bonne Petite Souris," a mouse changes into a fairy to help a good Queen defeat an evil King by hiding under his pillow to torment him and knocking out all his teeth.”

6. Fever with Teething • You are working in the ER and a 9 month old boy presents with T=101 and h/o T=102.5 at home. Mom reports that he has been teething. • Does teething account for the fever?

7. Fever with Teething • Teething sx • Fussiness • Increased sucking behavior • Loose stools • Increased drooling • Temp >100.6 should not be attributed to teething and should be evaluated

8. Cleaning/Brushing • At a 2 month well child visit, mom asks you if she should be doing anything to clean the baby’s mouth? A. No regular cleaning needed B. Give the baby 2 oz of water to wash out mouth C. Use a soft washcloth to clean gums D. Use a small toothbrush to clean gums

9. Cleaning/Brushing • AAPD recommends daily cleaning of infant’s gums before the eruption of first tooth • From birth to age 1 year recommend using moistened gauze or soft cloth to massage/clean gums • Use toothbrush only if parents feel comfortable • Don’t use toothpaste (b/c of fluoride ingestion)

10. First Toothbrush • At what age should parents start using a toothbrush to clean child’s mouth? • May start using from birth-1 year if parents feel comfortable • Start using at age 1 year if not done earlier

11. Toothpaste • When should parents start using toothpaste to clean child’s teeth and gums? • Start around age 2 years • Use small pea-sized amount

12. First Dental Visit • At a 4 month well child check, a conscientious mom asks you when she should take her son to the dentist for the first check-up? A. The month that he gets his first tooth B. At age 9 months C. At age 12 months D. At age 3 years

13. First Dental Visit • AAPD recommends first dental visit • Within 6 months of eruption of the first primary tooth • No later than 12 months of age • AAP recommends first dental visit • At 24 months of age • AAPD argues that by later age child may already having poor feeding habits and poor oral hygiene

14. First Dental Visit • Medical and dental history • Prenatal, perinatal, postnatal • Oral examination • Assess infant’s risk of developing oral and dental dz • Anticipatory guidance

15. Risk Factors for Caries • Poor oral hygiene • High sugar intake • Mother with high # cavities • Enamel defects • Premature birth • Special health care needs • Low socioeconomic status

16. At what age may cavities appear? • 10 months • 12 months • 18 months • 3 years Cavities may be visible as early as 10 mths

17. Caries and Cavities White lines Brown cavitations Gross cavitations Douglass et al, AAFP 2004

18. Parents with Cavities • At a 4 year well child visit, mom mentions that her daughter was found to have dental caries at her recent dental visit. • The pt’s two older siblings also have a history of multiple cavities. • Mom wants to know if cavities can “run in the family”? • What do you tell her?

19. Cavities as ID • By age 12 months, pt start to establish an oral environment that places them at risk for dental caries • Dental caries is an infectious, transmissable disease • Streptococcus mutans • Streptococcus sobrinus

20. Cavities as ID • Infants usually acquire from mom during 19-31 months of age • Mutans streptococci transmitted to child via saliva contact • Environmental tobacco smoke increases likelihood of streptococci colonization in children

21. Cavity Formation • Bacteria metabolize mono- and di- saccharide sugars  acid • Acid de-mineralizes teeth leading to cavity formation

22. The Bottle • At a 15 month well child check, mom tells you that her daughter uses a “sippy cup” during the day but likes to be put to sleep with a bottle of milk to drink at night. • What do you recommend to mom?

23. The Bottle • Concern that prolonged bottle or breast feeding creates oral environment that increases risk of early tooth decay • “Nursing caries” or “Bottle caries” or “Baby-bottle tooth decay”

24. The Bottle • AAPD recommends that after the first primary tooth begins to erupt • Infants should not be put to sleep with a bottle • Ad lib nocturnal breastfeeding should be avoided • Child should be encouraged to drink from a cup as they approach 1st birthday • Infants should be weaned from the bottle at 12-14 months of age

25. Thumb-sucking • A mom brings her 3 year old for a visit because he sucks his thumb at night and she is worried that this will “ruin his teeth.” • What do you tell her?

26. Thumb-sucking • Most children stop thumb-sucking by age 4 years with no harm done to their teeth • If still sucking thumb after age 4 years, then check with dentist • In most cases, don’t need to worry about thumb-sucking until age 6 years when permanent front teeth erupt

27. Fluoride • At a 2 year well child visit, mom explains that they drink mainly bottled water. She heard from a friend that bottled water doesn’t have fluoride and she wonders if she should use one of the liquid fluoride supplements? • What do you recommend?

28. Fluoride • How fluoride works • Ingested fluoride is incorporated into dentin and enamel of UNerupted teeth teeth are then more resistant to acid demineralization • Systemic fluoride is secreted in saliva and acts as bacteriostatic • Systemic fluoride accumulates in plaque where it decreases bacterial acid production and enhances enamel remineralization

29. Fluoride • Topical fluoride increases fluoride content of enamel of NEWLY erupted teeth and increases resistance to caries

30. Fluoride • Fluoride content varies • Local drinking water supply • Well water • Bottled water • Fluoride supplementation should be considered for any child who drinking water is deficient in fluoride (less than 0.6 ppm)

31. Fluoride • Fluoride supplementation also based on age • Most don’t supplement pt from birth to 6 mths even if fluoride <0.3 ppm • For ages 6 mths-3 yrs, supplement if fluoride <0.3 ppm • For ages 3 yrs-16 yrs, supplement if fluoride <0.6 ppm

32. Fluoride • Main side effect • Mottling of the teeth

33. Fluoride • Acute excessive fluoride intake • Doses <5 mg/kg • ½ of an 8-oz tube of toothpaste for a 5 yo  nausea, vomiting • Life-threatening hypocalcemia • Convulsions, tetany • Decreased cardiac contractility, arrhythmia, cardiac arrest

34. Bibliography • American Academy of Family Physicians familydoctor.org editorial staff. Dental Hygiene: How to Care for Your Child’s Teeth. http://familydoctor.org/online/famdocen/home/children/parents/kidshealthy/healthy-choice • American Dental Association. Tooth eruption: The primary teeth. JADA 2005; Vol 136: 1619. www.ada.org/goto/jada

35. Bibliography • Douglass, J, Douglass, A, and Silk, H. A Practical Guide to Infant Oral Health. American Family Physician 2004; 70: 2113-20, 2121-2. • Sanchez, O and Childers, N. Anticipatory Guidance in Infant Oral Health: Rationale and Recommendations. American Family Physician 2000; 61 (1): 115-20, 123-4.