Download Oral Health

Oral Health
Evelyn Berger-Jenkins, MD
Learning Objectives
 Recall normal pattern of primary and
secondary tooth development
 Identify common non-tooth related
pathology in the oral cavity
 Include screening for caries in well child
care, and establish prevention strategies
with parents
 Be aware of some of the evidence base
around controversial oral health issues
Case #1
 ‘A’ is a 3-week old, ex-FT boy with no
significant peri-natal complications.
He comes today for his first well-child
visit.
His mother had no complaints, but on
exam you notice the following:
3 week-old
Natal teeth
 Usually “normal variant”, but can be
associated with certain syndromes:
 Ellis van Creveld
 Hallermann-Streiff
 Jadassohn-Lewandowski
 What to do?
 X-ray
 Observe
 Remove if supernumery, feeding problems or
loose
Case #2
 ‘B’ is A’s twin sister. She has no natal
teeth, but mom is concerned about
this other bump in her mouth
Other “bumps” in the mouth…
 Mucocele
Ranula 
Other “bumps” in the mouth…
Other “bumps” in the mouth…
Case #3
 ‘C’ is a 4 month-old girl who presents
because her mother noticed “some
white stuff on her tongue”.
What is your differential diagnosis?
White stuff on tongue?
Case #4
 ‘D’ is a 10 month-old healthy girl
presenting for well-child care. Her
father complains that she’s been
taking less formula and wonders if it’s
because she’s teething. She had
eruption of her lower central incisors
at 6 months. He asks you when she
will get her two front teeth?
Normal tooth eruption
Permanent teeth
Case #5
 ‘E’ is an 18-month old boy with no
significant past medical history. He
presents with fever to 101.2 x 2
days. He had mild nasal congestion
yesterday.
Mom asks if his fever could be due to
teething?
Does teething cause fever?
Study
Methods
Outcome
Wake et al
(Australia, 2000)
Prospective study of 21 infants
assessed by staff for teething &
temperature
No association between teething
and fever
Macknin et al
(USA, 2000)
Prospective study of 125 infants
assessed by parents for teething
& temperature
Fever <38.5 was associated with
teething period of +/- 1 day
compared to non-teething days
Jaber et al
(Israel, 1991)
Prospective study of 46 infants.
Temperature assessed by
parents. Tooth eruption
assessed by staff.
Temperature increase to 37.9
associated with the day of tooth
eruption compared to
preceeding days
Peretz et al
(Colombia,
2003)
Retrospective questionnaire
completed by parents of 585
teething children
60% of teething children had
fever > 39, but no comparison
to fever in control children
Tighe M et al. Archives of Disease in Childhood. 2007;92:266
Does teething cause fever?
 Review of the evidence
 Mostly poor quality studies, i.e. retrospective or
relied on parent report
 Two prospective studies found an association
between increased temperature and the day of tooth
eruption +/- 1 day.
 Bottom line
 Infants with fever > 38.5, or with temperature 3838.5 on days other than the day of tooth eruption +/1 day should be evaluated for other sources of fever.
 Those presenting with low-grade fever (< 38.5)
during this window may be monitored conservatively
if well appearing.
Tighe M et al. Archives of Disease in Childhood. 2007;92:266
Case #6
 ‘F’ is a 2 year-old girl with mild
speech delay. Her mother is
concerned that her speech delay is
due to her “tongue tie”.
What do you tell her?
Ankyloglossia
 Prominent lingual
frenulum occurs in
~3-5% of children
 Complications may
include
 Feeding
(breastfeeding)
difficulties
 Articulation
problems
Ankyloglossia & speech delay?
 Review of the evidence
 No evidence for ankyloglossia and
speech/language delay
 Moderate evidence for moderate-severe
ankyloglossia and articulation problems
 Lingual frenulum will recede by 6 years
of age in majority of children  therefore
may observe conservatively
Case #7
 ‘G’ is a healthy 3 year-old boy
presenting for WCC. Mom has had
trouble getting him to sleep
throughout the night b/c he still
wakes for his bottle.
On exam you are presented with the
following:
Dental caries
Dental caries - Epidemiology
 The MOST common chronic disease in
children
 18% in 2-4 year olds  67% in 12-17 year olds
 Higher in certain ethnic groups
 Common in < 3 year-olds due to
 Primary teeth are thinner than permanent teeth
 Teeth that erupt 1st are less protected by saliva
Dental caries - Pathogenesis
Differential diagnosis of discolored
teeth
 Extrinsic factors
 Dyes in foods
(coffee), cigarettes…
 Medications
(tetracyclines,
anticholinergics)
 Metals (iron, lead)
 Trauma
Tetracycline discoloration
 Intrinsic factors
 Hyperbilirubinemia
 Poryphyria
Dental caries - Management
 Remove plaque and decayed teeth
 PREVENTION, PREVENTION,
PREVENTION!
 Oral hygiene
 Limit substrate (carbohydrates)
 Fluoride
Prevention – oral hygiene
Age
Toothbrushing
Recommendations
(CDC 2001)
< 1-2 years Parent cleans with cloth
or soft toothbrush.
No toothpaste
2-6 years
Pea-sized amount of
fluoride-containing
toothpaste twice per
day
Floss Qday
Parent supervises
> 6 years
Brush independently
twice per day
Preventive – Dental Home
 Beginning at 6-mo
pediatricians should:




Assess mother’s oral
health.
Assess oral health
risks*
Examine mouth/teeth
and recognize
signs/symptoms of
caries.
Assess child’s exposure
to fluoride.
 *Send high-risk
patients to dentist
sooner
Case #7 continued…
 Mom asks if this could have been
prevented if she had given him a
vitamin. Her friend is giving her child
supplemental fluoride, but you never
prescribed this for her. Why?
Fluoride
 Anti-cariogenic

Decreases demineralization by
(1) combining into & strengthening enamel
(2) decreasing production of acid from
bacteria
 Present in 2/3 of all US public water
supplies (http://apps.nccd.cdc.gov/MWF/Index.asp) and
most toothpastes
 Supplement if low fluoride levels in water
supply, or child doesn’t drink water
Fluoride supplementation
Case #8
 You’re in the ED and are presented
with ‘H’, a 5 year-old boy who comes
in with his front tooth in a cup of salt
water. It fell out when he was hit in
the face during a baseball game.
Dental trauma
 Were these likely his primary or
secondary teeth?
 What should you do with the patient?
The tooth?
Dental trauma - management
 Don’t forget to assess for head trauma
 Call OMF surgery early
 Utility of preserving the avulsed tooth?
 Avulsed primary teeth should NOT be
reimplanted
 Avulsed permanent teeth should be reimplanted STAT (before 15 minutes) or stored in
cold milk until they can be restored
Case #9
 ‘I’ is a 12 year-old girl with no
significant past medical history. She
sucks her thumb, and her mother is
asking your opinion about obtaining
braces for the following problem:
Malocclusion
 Causes:
 Hereditary
 Behaviors (bottles, pacifiers and thumb
sucking esp. beyond 5 yrs.)
 Treatment:
 Mostly cosmetic
 Orthodontist referral best if early
Case #10
 ‘J’ is a 14 year-old girl who is
preparing for her quinceañera. She
asks you whether there is any
“downside” to using teeth whiteners,
and whether you could recommend a
whitening method.
What do you tell her?
Tooth whiteners?
 Lee SS et al.
 Recent review of tooth whitening in
children
 Conclusions:
 30-50% of patients experience gingival
irritation (increased in children)
 Excessive peroxide exposure can cause
pulpal/root damage esp. in < 18 year olds
 Whitening during mixed dentition will result
in uneven results
Lee SS et al. Pediatric Dentistry. 2005 Sep-Oct;27(5):362-8
References
 MAIN:


Website AAP Health Topics, Oral Health:
www.aap.org/healthtopics/oralhealth.cfm
Preventive Oral Health Intervention for Pediatricians.
Pediatrics 2008;122:1387-1394
 OTHER:
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Natal Teeth A Review: J Natl Med Assoc. 2006 Feb.
98(2):226-8
Delayed Tooth Eruption: Am J Orthod Dentofacial
Orthop. 2004 Oct. 126(4):432-45
Fever & Teething: Archives of Disease in Childhood.
2007. 92:266
Ankyloglossia: J Paediatr Child Health 2005 May-Jun.
41(5-6):246-50
Fluoride content in various water sources:
http://apps.nccd.cdc.gov/MWF/Index.asp
The End – SMILE!