Chapter 17: Oral Medicine & Dentistry

Concept of the Dental Home

Establishment of a dental home during the infant phase provides a vital foundation for oral health promotion and prevention of oral disease, such as early childhood caries. Analogous to the American Academy of Pediatrics concept of a medical home, the dental home has been defined by the American Academy of Pediatric Dentistry as “the ongoing relationship between the dentist and the patient, inclusive of all aspects of oral health care delivered in a comprehensive, continuously accessible, coordinated, and family-centered way.” The dental home encompasses all aspects of oral health that result from the interaction of the patient, parents, dentists, dental professionals, and nondental professionals. A dental home is initiated by the determination of involved individuals and their collaborative interaction to establish awareness of factors influencing the patient’s oral health.

Achieving optimal oral health care as part of a dental home requires a dentist who is knowledgeable about pediatric oral health or a pediatric dentist (a specialist in care for children and those with more complex oral health needs), in partnership with the child’s primary caregiver. Together, the dentist and primary caregiver can develop a comprehensive preventive program based on an assessment of disease susceptibility. Similar to preventive care guidelines as part of a medical home, the preventive oral health plan for children provides anticipatory guidance for caregivers on age-appropriate preventive measures. These include oral hygiene practices, the importance of fluoride, dietary guidance, dental trauma, and the value of a dental home.

Addressing risk factors for early childhood caries is a central component of anticipatory guidance during routine visits to medical and dental providers. Beyond the focus on preventive oral health, the dental home provides access to comprehensive, routine, and urgent dental care, and facilitates referral to other dental and medical providers as indicated. By providing continuously accessible dental care, the time and cost of urgent or emergent dental treatment may be reduced for the family and society.

Prenatal and Perinatal Factors and Infant Oral Health Care

Oral health promotion by health care providers during the prenatal and perinatal periods provides preventive information to mothers and other family members. Mothers may be unaware of the potential consequences of their own oral health, which can impact their systemic health, pregnancies, and the well-being of their children. Also, a mother’s and/or primary caregiver’s oral health knowledge, behaviors, and attitudes have an influence on the oral health trajectory of children. Infant oral health care is the foundation for preventive dental care. The infant oral health program should (1) establish with caregivers the goals of oral health, (2) inform caregivers of their role in reaching these goals, (3) motivate caregivers to learn and practice optimal preventive oral health behaviors, and (4) initiate a long-term dental care relationship with caregivers. These goals are enhanced through anticipatory guidance on topics such as teething, oral hygiene, diet, fluoride, injury prevention, nonnutritive sucking habits, and regular dental health supervision. This approach advances dental care from monitoring for disease to oral health promotion.

Typically, pediatricians encounter newborns and infants at an earlier age than dental providers, providing them an opportunity to address risk factors associated with early childhood caries. Pediatricians are encouraged to incorporate caries-risk assessment and anticipatory guidance focused on oral health into their routine practice. Caries-risk assessment estimates the likelihood of developing carious lesions based on the complex interaction of risk factors at multiple levels (individual, family, community, and social environment). Risk indicators for the age group 0 to 3 years of age that predict development of dental caries are listed in caries-risk assessment forms that are available for physicians and other nondental health care providers through the American Academy of Pediatric Dentistry and American Academy of Pediatrics. By 6 months of age, every infant should have a caries-risk assessment performed by a pediatric health care provider. Since the risk of caries increases with age, anticipatory guidance by pediatricians and nondental health care providers is recommended beyond age 3 years as part of routine pediatric care.

Exam Positioning

For children under age 3, a knee-to-knee position allows the provider to complete the oral examination in a safe and comfortable way (Figure 17–1). The parent is instructed to sit facing the provider with the knees of both the parent and provider touching or interlocking to create a table. The infant is then positioned on the parent’s lap facing the parent, with each leg wrapped around the parent’s waist. The child’s head is lowered onto a pillow on the provider’s lap for the examination, with the parent being instructed to stabilize the child’s arms and legs with their hands and elbows, respectively. Crying during the examination is a normal response in healthy children and will allow for better visualization of the oral cavity. For older, more cooperative children, the oral examination can be performed on the dental chair. With the chair reclined and the patient in a supine position, a pillow can be added for support for the legs depending on the size of the patient.

During the examination, the clinician assesses the extra-oral tissues, intra-oral hard and soft tissues, and overall oral hygiene maintenance.

Extra-Oral Examination

Extra-oral examination includes assessing the overall symmetry of the face. This can easily be done by holding a piece of floss across the patient’s facial midline. Evaluation of the face can be done by dividing the face in equal thirds. The facial upper third extends from the hair line to the glabella, the middle third spans from the glabella to the base of the nose (subnasale), and the lower third extends from subnasale to the chin. The length of each facial thirds is usually equal or similar. Extraoral findings such as muscle strain over the chin can also point to a skeletal or orthodontic problem. The submandibular glands and lymph nodes should be palpated to identify any enlargement or pain. A temperomandibular joint (TMJ) examination should determine the range of motion and any deviation while opening or closing the jaw. The preauricular area is palpated to determine the presence of any TMJ crepitations or clicking indicative of underlying joint pathology.

Intra-Oral Soft Tissue Examination

The mouth of the normal newborn is lined with an intact, smooth, moist, shiny mucosa (Figure 17–2). The alveolar ridges are continuous and relatively smooth. Within the alveolar bone are numerous tooth buds, which at birth are mostly primary teeth. The sagittal and vertical maxillo-mandibular relationships are different at birth, with an anterior open bite being considered physiologic before the onset of tooth eruption. The mouth is more triangularly shaped and the oral cavity is small and filled by the tongue due to a small and slightly retrognathic lower jaw. This pseudo micrognathia is due to ventral positioning of the fetus to facilitate its passage through the birth canal and will generally correct after birth.

Frena

Small maxillary and mandibular frena can be found in the anterior midline region (Figure 17–3), and small accessory frena are often present posteriorly. A more prominent midline maxillary labial frenum, which is observed in 25% of children, tends to diminish in size and recede apically with normal development and the eruption of teeth.

The tongue is connected to the floor of the mouth by the lingual frenum (Figures 17–4 and 17–5), whereas the upper lip is connected to gingiva above the upper central incisors by the maxillary frenum. With ankyloglossia, the attachment is tight, closer to the tip of the tongue or high up on the alveolar ridge (see Figure 17–5) and may restrict movement. Ankyloglossia typically does not inhibit normal growth and development; however, it can cause feeding problems, such as difficulty latching or pain during nursing. These concerns can be addressed with frenotomy of the lingual frenum shortly after birth. In most cases breastfeeding will be improved. In contrast, frenotomy of the maxillary frenum is rarely indicated as there is no evidence that this reduces breastfeeding difficulties.

Soft Tissue Variations

The most common soft tissue pathology in newborns are neonatal cysts, including Bohn’s nodules, Epstein pearls, and dental lamina cysts. Bohn’s nodules are remnants of mucous gland tissue that occur on the buccal and lingual aspects of the alveolar ridges. Epstein pearls are remnants of epithelial tissue trapped at the time of palatal fusion during early fetal development and are found along the mid-palatal raphe. Dental lamina cysts are remnants of the dental lamina and are typically located on the alveolar mucosa. These cysts are 1–3 mm round, smooth, nontender white, gray, or yellow nodules that are self-limiting in nature and typically resolve by 3 months of age.

Intra-Oral Hard Tissue

The development of alveolar bone is evident with development of tooth buds and later eruption of the primary teeth and permanent teeth. Alveolar bone encases the developing tooth buds and supports the teeth through periodontal ligament attachments. Alveolar ridges are usually horseshoe-shaped at birth and the mandibular and maxillary alveolar ridges contact each other at their most posterior aspects at birth. With eruption of teeth during further development, these ridges will no longer contact each other.

Hard tissue formation of the primary teeth begins at approximately 14 weeks in utero, with all 20 primary teeth being calcified to varying degrees, with traces of the enamel of first permanent molars being present at birth. Primary teeth generally begin to erupt around 7 months of age but may appear as early as 3–4 months or as late as 12–16 months of age. A complete set of primary teeth (20 teeth) is usually erupted between 30 and 36 months. Although there are variations, usually anterior teeth erupt before posterior teeth, and mandibular teeth before their maxillary counterparts.

Between 6 and 7 years of age, the first permanent molars erupt distal to the existing primary second molars. This phase of development, when both primary and permanent teeth simultaneously exist, is known as the mixed dentition. Following eruption of the first permanent molars, mandibular permanent central incisors erupt, replacing existing primary central incisors and resulting in the exfoliation of the first primary tooth. Children continue to exfoliate primary teeth as their permanent successors erupt until approximately the age of 12, with the maxillary canines typically being the final primary tooth to be shed. Around the same time, the second permanent molars erupt, followed later in adolescence by the development of the permanent third molars, colloquially referred to as wisdom teeth. Once the patient has erupted a complete set of permanent teeth (with the exception of third molars), they are considered to have adolescent dentition.

Tooth Numbering Systems

Tooth numbering systems enable clinicians to more effectively communicate unequivocally about a patient’s teeth. In the United States, the Universal Numbering System (Figure 17–6) is used, which assigns the uppercase letters A–T for primary teeth and the numbers 1–32 for permanent teeth. The initial designation begins on the upper right, most posterior tooth and continues along the upper teeth to the left side. The count then drops to the lower, most posterior tooth on the left side and continues along the bottom teeth to end on the lower right side.

Hard Tissue Variations

Potential variations in dental hard tissues involve the number and size of primary and permanent teeth. When an extra tooth or teeth are present they are referred to as supernumerary tooth/teeth and the condition is known as hyperdontia. If a supernumerary tooth occurs in the maxillary incisor midline area it is referred to as mesiodentes. The removal of such a tooth is recommended especially if it hinders eruption of the adjacent permanent incisors.

Tooth agenesis is rare in the primary dentition but occurs with an incidence of 5% in the permanent dentition. Depending on the number of teeth that are congenitally missing, the condition is referred to as either hypodontia (less than six absent teeth) or oligodontia (more than six absent teeth). The most frequently missing permanent teeth are the third molars, followed by the mandibular second premolars and maxillary lateral incisors. Tooth agenesis is caused by several independent defective genes, which can act alone or in combination with other genes. It can occur as an isolated problem but is common with cleft lip/cleft palate or as part of the phenotype of over 200 syndromes, including ectodermal dyplasias.

Minor variations in the size of teeth are common. Macrodontia refers to teeth that are abnormally large and microdontia is the term given to teeth that are smaller than the usually expected size. Apart from the number and shape of the teeth, there may also be abnormalities in the overall formation of the hard tissue structures such as enamel and dentin (amelogenesis imperfecta or dentinogenesis imperfecta, respectively).

Eruption Symptoms

Many symptoms are ascribed to the process of tooth eruption or teething. However, any temporal association with fever, upper respiratory infection, or systemic illness is coincidental rather than related to the eruption process. Attributing fever to teething without a thorough diagnostic evaluation for other sources has resulted in missing serious organic disease.

Common therapies for teething pain include the application of over the counter teething gels or liquids. For teething children, their main ingredient, benzocaine, can rarely cause methemoglobinemia. While “natural” benzocaine-free formulations are available, systemic analgesics such as acetaminophen or ibuprofen are safer and more effective. Chewing on a teething object can be beneficial, if only for distraction purposes.

Occasionally, swelling of the alveolar mucosa overlying an erupting tooth can be seen. This usually asymptomatic condition appears as localized red to purple, round, raised, and smooth lesion. Treatment is rarely needed as these eruption cysts/hematomas resolve with tooth eruption.

Pathologies of Tooth Eruption

Natal Teeth

On rare occasions (1:3000), natal teeth are present at birth and neonatal teeth erupt into the oral cavity within the first month of life. These are most commonly (85%) primary mandibular incisors. A radiograph should be taken to determine whether they are regular or supernumerary teeth (10%). Although the preferred approach is to leave the tooth in place, natal teeth that are supernumerary, hypermobile, or of inferior structural quality should be extracted. Other indications for removal of natal teeth include nursing difficulties and when their sharp incisal edges cause laceration of the ventral surface of the infant’s tongue (Riga-Fede disease).

Delayed Eruption

Premature loss of a primary tooth can either delay or accelerate eruption of the underlying permanent tooth. Accelerated eruption occurs when the primary tooth is removed within 6–9 months of its normal exfoliation, but loss of the primary tooth more than 1 year before its expected exfoliation typically delays eruption of its successor. The loss of a primary tooth often causes adjacent teeth to tip or drift into the resulting space, leading to space loss for the underlying permanent tooth. Placement of a space maintainer can prevent such space loss.

Other local factors delaying or preventing tooth eruption include supernumerary teeth, cysts, odontogenic tumors, over-retained or ankylosed primary teeth, and impacted teeth. A generalized delay in eruption may be associated with global developmental delays, endocrinopathies, and other systemic conditions.

Ectopic Eruption

Insufficient space in the dental arch may cause permanent teeth to erupt ectopically and cause a usually painless root resorption of the adjacent primary tooth. This phenomenon is observed most commonly with the maxillary first permanent molars.

Occasionally, mandibular incisors erupt lingually and lead to over-retention of the primary predecessor, resulting in a “double row of teeth.” If the primary tooth is still firmly in place, the dentist should remove it to allow its successor to drift into proper position.

Impaction

Impaction occurs when a permanent tooth is prevented from erupting. Although crowding is a frequent reason, over-retained primary or supernumerary teeth are other causes. The teeth most often affected in the developing dentition are the maxillary incisors and canines. Often, they are brought into correct alignment by early extraction of the preceding or adjacent primary teeth. If this approach is ineffective, surgical exposure of the impacted tooth and orthodontic treatment are indicated.

Dental caries is the most common chronic disease of childhood and the most prevalent unmet health need of US children. Largely a disease of poverty, dental caries primarily affects almost 80% of children and adolescents living in low-income families.

Early Childhood Caries

Formerly termed “baby bottle tooth decay” or “nursing bottle caries,” early childhood caries (ECC) is a particularly virulent and rapidly progressive form of caries that begins on the smooth surfaces of the teeth soon after eruption. According to the American Academy of Pediatric Dentistry (AAPD), ECC is defined as one or more decayed (d), missing (m), or filled (f) tooth surfaces (s) in any primary tooth in a child under 6 years of age. The disease typically involves the maxillary incisors, but any other teeth may be affected. A lack of adequate preventive care and poor feeding habits can place children at high risk for ECC.

Any sign of smooth-surface caries in a child less than 3 years is termed severe ECC (S-ECC). From 3 to 5 years, a dmfs score of 1 or more in maxillary front teeth or a total dmfs score of 4 or higher must be present to make a diagnosis of S-ECC. Children with S-ECC are at higher risk for new carious lesions. They are also likely to experience frequent hospitalizations, emergency department visits, and school absences due to the severity of existing carious lesions. The presence of S-ECC can also result in below-normal height and weight gain and diminished oral health-related quality of life for the affected child. Although S-ECC can affect all children, it is 32 times more likely in children who consume sugary foods and whose mothers are of low socioeconomic status and education level.

Pathogenesis

Development of caries requires the interaction of four factors: (1) a host (tooth in the oral environment); (2) a suitable dietary substrate (fermentable carbohydrates); (3) cariogenic microorganisms that adhere to the tooth; and (4) time, measured as the frequency of exposure to fermentable carbohydrates and the duration of acid exposure. The main organisms implicated in the initiation of caries are Streptococcus mutans (MS) and Streptococcus sobrinus. Lactobacillus acidophilus and Lactobacillus casei are also linked to the progression of caries. MS organisms are most commonly passed from mother to child. A “window of infectivity” between ages 19 and 30 months has been described, but MS colonization of the oral cavity can occur as early as 3 months of age. Earlier colonization increases the risk of caries.

Dental plaque is an adherent biofilm on the tooth surface that harbors acidogenic bacteria in close proximity to the enamel. As bacteria metabolize sucrose, they produce lactic acid that solubilizes calcium phosphate in tooth enamel. Demineralization of the dental enamel occurs below pH 5.5 and is the first step in cariogenesis. The flow rate of saliva and its buffering capacity are important modifiers of demineralization. Demineralization of enamel and dentin can be halted or even reversed by redeposition of calcium, phosphate, and fluoride from saliva.

If caries progresses it penetrates the enamel, advancing through the dentin toward the pulp of the tooth. In response, blood vessels in the pulp dilate and inflammatory cells begin to infiltrate (pulpitis), resulting in tooth pain. When the carious lesion is still untreated, pulp invasion will occur, triggering invasion of more inflammatory cells and the eventual formation of a small pulpal abscess. Once the pulp in the root of the tooth becomes necrotic, a periapical abscess develops (Figure 17–7), which usually causes severe pain, fever, and swelling.

Caries Prevention

Since caregivers are more likely to establish a medical home for well-child visits at birth and prior to initiating a dental home, medical offices have opportunities to provide preventive dental services that includes dental screening, caries risk assessment, caregiver counseling about their child’s oral health, and referrals to dentists for establishment of a dental home or follow-up for concerns.

Prevention of dental caries necessitates restoration of the delicate balance between pathologic factors and protective influences. Pathologic factors include a susceptible host, cariogenic bacteria, deficient fluoride exposure, and fermentable carbohydrates. The most studied protective influences include fluoride, sugar substitutes (xylitol), and frequency of brushing. Among these, only fluoride from topical and systemic sources (food, beverages, drinking water, and oral care products) has demonstrated a consistent protective effect.

Dietary Guidelines

Since dental caries requires frequent exposure to fermentable carbohydrates, poor feeding habits increase the risk for caries development. Dietary practices that can reduce caries risk in nursing infants include giving only water in the bottle at bedtime. Infants should also be weaned from the bottle between 12 and 18 months of age and encouraged to drink from an uncovered cup (rather than a no-spill training cup). Soda, 100% juice, and powdered beverages should be avoided.

Dietary counseling should be based on maintaining a diet in accordance with the World Health Organization (WHO) recommendations in which free-sugar consumption is less than 10% of total daily energy intake and preferably below 5% of the total energy intake. Foods considered to be protective against caries are high in fat, protein, and minerals such as milk and cheese, which contain calcium and phosphate.

Oral Hygiene

Soon after birth, caregivers should clean intra-oral surfaces on a daily basis using a moist, soft cloth. Once the teeth erupt, oral hygiene must be practiced in earnest, particularly in high-risk children as caries formation has been associated with biofilm accumulation on tooth surfaces. Due to a lack of manual dexterity in children younger than 8 years of age, caregivers should be brushing, as well as flossing for their children’s teeth if there is no spacing between the teeth. With respect to caries, mechanical removal of biofilm from tooth surfaces without concomitant use of fluoridated toothpaste has a weaker association with caries reduction. Thus, as part of oral hygiene practices, fluoridated toothpaste is recommended to reduce risk of caries in the primary and permanent dentition. Caregivers should be instructed regarding the appropriate amount of fluoridated toothpaste at each brushing; “smear or rice-sized amount” (under age 3 years) or “pea-sized” amount (ages 3–6 years) of toothpaste. The beneficial effect of fluoride-containing toothpaste can be maximized by brushing teeth twice daily and either avoiding or rinsing minimally after brushing. Supplemental fluoride use is based on the individual’s caries risk.

Fluoride

Fluoride is a one of the most effective means of caries prevention through the topical and systemic mechanisms of action. By both routes of administration, fluoride can affect the dentin and enamel of erupted and unerupted teeth. Topical application inhibits bacterial metabolism by interfering with enzyme activity, inhibiting demineralization, and enhancing remineralization.

Systemic benefits are achieved by oral ingestion from sources such as fluoridated drinking water, beverages, infant formulas, and prepared food. The U.S. Department of Health and Human Services has specified a level of 0.7 ppm fluoride in community water supplies to balance the benefits of preventing dental caries while minimizing the risk for enamel fluorosis. Infants receiving concentrated infant formula as the main source of nutrition are at increased risk for enamel fluorosis in the permanent dentition if fluoride-containing formulas are reconstituted with fluoridated drinking water.

Fluoride supplements also help reduce dental caries prevalence and are a consideration for children at high caries risk and without access to fluoridated community water, depending on their age and existing fluoride exposure from other sources. A child’s true exposure to all sources of fluoride must be thoroughly evaluated before supplements are prescribed so as to avoid enamel fluorosis.

A. Fluoride Varnish for High-Risk Populations

Applications of fluoride varnish during well-child visits with physicians is successful in reducing dental caries among vulnerable children (ICD-10-CM Diagnosis Code Z29.3: Encounter for Prophylactic Fluoride Administration). The sticky nature of the varnish’s resin base allows for extended contact time of its fluoride content with the tooth surface.

The varnish in single-dose packages (0.3–0.5 mL) should be stirred before application and the contents of larger tubes (5 mL) massaged to dissolve any precipitated fluoride. The former are preferable because consistent availability of fluoride cannot be guaranteed with multidose packages. The average amount of varnish needed depends on the number of teeth present and ranges from 0.1 mL for infants to 0.3 mL for preschool children. Teeth should be dried with gauze before the varnish is applied with a small brush. It will set quickly to a dull yellow film upon contact with saliva. Caregivers should be instructed not to brush or floss and to give their children only soft foods until the next morning to provide enough time for absorption of the fluoride into enamel.

B. Other Adjunctive Measures

Xylitol containing products are marketed in many forms (eg, gums, mints, lollipops, chewable tablets, toothpastes, mouthwashes) as an adjunctive measure in caries prevention. Xylitol is considered a noncariogenic substitute due to the inability of oral bacteria to metabolize this five-carbon sugar alcohol. However, recent systematic reviews suggest that there is limited evidence for caries reduction from xylitol-containing products.

Treatment of Caries

Caries is usually diagnosed by visual and tactile oral examination supplemented by radiographs to detect caries on the surfaces between teeth. The initial defect observed on enamel beneath dental plaque is the so-called “white-spot lesion,” a white, chalky, decalcified area along the gingival margin or on approximated tooth surfaces. Frank carious lesions are light to dark brown spots or cavities of varying size on the tooth. A light shade of brown indicates rampant decay, while arrested caries is almost black in color.

In the early stages of decay, the tooth may be sensitive to temperature changes or sweets. Removing the carious tooth structure and filling the early defect with a restorative material can repair the tooth. As decay progresses deeper into the pulp, inflammation and pain increase. Eventually, the entire pulp becomes necrotic, and a choice must be made between root canal therapy (pulpectomy) and removal of the tooth. In the presence of cellulitis, extraction and antibiotic therapy are the treatments of choice.

When restorative materials are used to repair a tooth, the primary choices include dental amalgam, composite resin, or glass ionomer cement. For primary molars with extensive caries and/or pulpal involvement, full coverage crowns are the restorations of choice and these are available as preformed stainless steel crowns and in various cosmetic iterations.

Silver diamine fluoride has been utilized to slow or arrest caries progression in select patients. Its use may be considered in circumstances where the risk of morbidity or mortality under sedation or general anesthesia outweighs the benefit of definitive restorations. Once applied, the medicament produces a gray-black discoloration of carious defects of treated teeth and may be interpreted as caries.

Periodontal diseases are a group of conditions affecting a tooth’s supporting structures: bone, gingiva, and periodontal ligament (Figure 17–8). Plaque and bacterial accumulation in the gingival sulcus cause a localized inflammation of the gingival tissue adjacent to a tooth. This initial phase, called dental plaque-induced gingivitis, is found almost universally in children and adolescents. This affects about half of the population by 5 years of age and reaches a prevalence of nearly 100% at puberty. Gingivitis is considered reversible, and generally responds well to removal of dental plaque and improved oral hygiene.

Periodontitis, the subsequent phase, is characterized by irreversible loss of the periodontal attachment and destruction of bone. Abnormalities in neutrophil function such as chemotaxis, phagocytosis, and antibacterial activity increase the risk of periodontitis. Actinobacillus actinomycetemcomitans in combination with bacteroides species are implicated in this disease process. If oral hygiene does not improve and local contributing factors are not removed, chronic periodontitis can become more severe, resulting in generalized loss of the periodontal attachment. Chronic periodontitis is most easily arrested in its early stages before deep pockets develop with gradual loss of attachment. Aggressive periodontitis, previously labeled as early-onset periodontitis, is defined by rapid attachment loss and alveolar bone destruction. Treatment consists of combined surgical and nonsurgical mechanical debridement, and antibiotic therapy.

Concomitant medical conditions, hormonal alterations associated with the onset of puberty, certain medications, and malnutrition can intensify the inflammatory response to plaque. Periodontitis as a manifestation of systemic disease is associated with hematological (acquired neutropenia, leukemias) or genetic disorders, such as Down, Papillon-Lefèvre, Chediak-Higashi, hypophosphatasia, and leukocyte adhesion deficiency syndromes. The incidence of necrotizing periodontal diseases is lower (1%) in North America than in developing countries (2%–5%). These diseases are characterized by interproximal ulceration and necrosis of the dental papillae, rapid onset of dental pain, and often fever. Predisposing factors include viral infections, malnutrition, emotional stress, and systemic disease. The condition usually responds well to mechanical debridement, improved oral hygiene, and antibiotic therapy for febrile patients.

Orofacial Trauma

Orofacial trauma consists mainly of abrasion or laceration of the lips, gingiva, tongue, or oral mucosa (including the frena), without damage to the teeth. Lacerations should be cleansed, inspected for foreign bodies, and sutured if necessary. Radiographs of lacerations of the tongue, lips, or cheeks should be taken to detect missing tooth fragments or other foreign bodies as palpation alone may not be adequate. All patients with facial trauma should be evaluated for jaw fractures. Blows to the chin are among the most common childhood orofacial traumas. They are also a leading cause of condylar fracture in the pediatric population. Condylar fracture should be suspected if significant pain or deviation occurs when the mouth is opened.

Tooth-related trauma affects the dental hard tissues and pulp, the alveolar process, and the periodontal tissues. The range of dental injuries includes root, crown, and alveolar fractures; concussion, subluxation, intrusive, extrusive, and lateral luxations; and avulsion. Figure 17–9 demonstrates different degrees of tooth fractures, and Figure 17–10 shows the types of luxation injuries.

Primary Teeth

The most common injuries in the primary dentition are luxation injuries, with the greatest incidence of trauma occurring between 2 and 3 years of age. Treatment recommendations are primarily guided by assessing the risk of damage to the developing permanent tooth which is in close proximity to the apex of the root of the primary tooth. Parents should be advised of any permanent tooth complications such as enamel hypocalcification, dilacerations (severe angular distortions of the crown or root of a tooth), ectopic eruption, or impaction caused by intrusion injuries of the primary maxillary anterior teeth. An intrusive luxation is usually observed for a period to discern whether the tooth will spontaneously re-erupt (see Figure 17–10) unless the root of the primary tooth is impinging on the crown of the permanent tooth bud as diagnosed with an occlusal radiograph. Severe luxation in any direction is treated with extraction. Avulsed primary teeth are rarely replanted because the risk of ankylosis and damage to the permanent tooth successor outweigh the esthetic benefit of having the primary tooth in place for a few years. In a root fracture, the crown and apical fragment are generally extracted, but the latter should be left for physiologic resorption if its retrieval would result in potential damage to the permanent tooth.

When planning treatment, other important factors such as the child’s maturity and level of cooperation should be considered along with the time to exfoliation of the injured tooth. Complex procedures such as root canal treatment, crown placement, and splinting require high levels of cooperation when compared to extraction and must be carefully discussed with parents if advanced behavior guidance modalities such as sedation or general anesthesia are required.

Permanent Teeth

The most common injury in the permanent dentition is crown fracture occurring secondary to falls, motor vehicle accidents, violence, and sports. Treatment is aimed at preserving the health of the pulp. Intrusions of permanent teeth are corrected with repositioning unless the tooth is immature and has incomplete root formation, the intrusion is minor (less than 3 mm), or there is no re-eruption after a few weeks. Lateral and extrusive luxations are generally repositioned and splinted for up to 2 weeks. Splints should stabilize the tooth in correct position while allowing physiologic movement of the tooth, good oral hygiene, and nontraumatic removal.

Because the prognosis for viability worsens rapidly as time outside the mouth increases, an avulsed permanent tooth should be replanted into its socket as soon as possible at or near the accident scene after gentle rinsing with clean water. The patient must seek emergency dental care immediately thereafter. Hank’s balanced salt solution (HBSS) is the best storage and transport medium for avulsed teeth that are to be replanted at a distant site. The next best storage mediums in decreasing order are milk, saline, saliva (buccal vestibule), or water. The commercially available FDA-approved Save-a-Tooth kit which contains HBSS should be part of first-aid kits in school and sports facilities. Root canal treatment is necessary in the majority of cases to prevent inflammatory root resorption and needs to be initiated within 10 days from time of the initial injury.

Alveolar Fracture

Severe injuries can result in a fractured alveolus. The alveolar ridge and teeth within the fractured segment often move together when palpated and result in a disturbance in occlusion. Fractures should be evaluated with radiographs to determine their extent and involvement with the remaining teeth. The entire fractured segment should be repositioned and splinted with the teeth in place for 4 weeks after gingival lacerations are sutured. Removal of teeth which are firmly positioned in the alveolar segment is not indicated.

Home Care, Follow-Up, and Prevention

Healing outcomes are improved when home care instructions are observed and follow-up visits to the dentist are made. Excellent oral hygiene and rinsing with 0.12% chlorhexidine gluconate for 1–2 weeks reduces the presence of bacteria in the affected areas. A soft diet for 1–2 weeks and prevention of further injury is critical to healing and parents should be advised to keep children out of contact sports and rough play during this sensitive time of healing. Additionally, infants should be restricted from using a pacifier. During dental follow-up visits, the vitality of the teeth will be assessed through temperature, percussion, palpation, and radiographic testing.

Following healing of the injury, prevention of future injuries should be encouraged through the use of mouthguards for sports prone to injury.

Antibiotic Usage

There is limited evidence for the use of systemic antibiotics for dental injuries; however, antibiotic use remains at the discretion of the clinician as traumatic dental injuries frequently occur in unclean environments and are often accompanied by soft tissue lacerations, maxillofacial trauma, and affect medically compromised patients. For avulsion injuries, tetracycline is the antibiotic of choice for the first week after replantation of an avulsed tooth. While one of the significant side effects of tetracyclines is permanent tooth discoloration, such a risk is more likely to occur with longer courses (> 21 days) that are generally not given to children who are younger than 8 years of age. Per the International Association for Dental Traumatology (IADT), penicillin or amoxicillin can also be prescribed as an effective alternative to tetracycline for children under 12 years of age for whom the risk for discoloration of permanent teeth may be considered a significant concern.

Odontogenic Infections

Odontogenic infections can result from carious lesions, restorations approximating the pulp tissue, periodontal complications, and dental trauma. If left untreated, pain, a dental abscess, and facial cellulitis can result. These sequelae can lead to serious complications such as dehydration from difficulties with eating or drinking, cavernous sinus thrombosis, and Ludwig’s angina. While acetaminophen or ibuprofen can help relieve pain, prompt intervention and removal of the source of infection is needed to avoid adverse sequelae. Topical medications are of limited value for pain relief.

Alveolar Abscess

When left untreated, the infection that causes necrosis of the pulp tissue can spread outward from the apical foramen of the root of the tooth through bone and periosteum to produce an alveolar abscess. In its acute form, the abscess presents as a painful and diffuse infection of the gingival soft tissues that requires immediate attention. Treatment includes root canal therapy or extraction for the drainage of pus from the site of infection and for pain relief. A chronic alveolar abscess (or parulis) is a localized smaller swelling confined to the gingival tissue associated with the infected tooth. A parulis does not represent an urgent situation and antibiotic therapy is not warranted as the pus is draining through a fistula tract. Definitive treatment includes root canal therapy or extraction of the offending tooth.

Facial Cellulitis

Facial cellulitis results if the odontogenic infection invades the facial spaces. Elevated temperature (> 38.8°C), lethargy, difficulty swallowing, and difficulty breathing are signs of serious infections. Swelling of the midface—especially the bridge of the nose and the lower eyelid—should be urgently evaluated as a potential dental infection. Depending on the clinical situation and the patient’s overall health, treatment choices range from treating or extracting the offending tooth/teeth, with antibiotic coverage, to achieve drainage and eliminate the source of infection. Occasionally, treatment is delayed for several days while antibiotics are administered orally or IV (for hospitalized patients) so that the infection can be properly drained. The first-line antibiotic of choice is penicillin and secondarily clindamycin or ampicillin-sulbactam (Unasyn). Hospitalization is a prudent choice for younger children with severe facial cellulitis especially if other systemic signs and symptoms are present—fever, dehydration, airway compromise, or possible noncompliance.

Oral Conditions

Children with special health care needs (C-SHCN) may have anomalies affecting their teeth and/or oral soft tissues as a primary manifestation of a systemic condition or secondary to medical interventions. For children with Trisomy 21 for example, conditions such as hypodontia and delayed eruption are considered primary oral manifestations of the syndrome. Rare systemic conditions such as osteogenesis imperfecta can be associated with dentinogenesis imperfecta—a defect affecting the dentin of primary and permanent dentition resulting in early loss of teeth if left unrecognized and untreated.

Medical interventions such as chemotherapy and radiation therapy can have immediate and long-term oral effects. Most immediate are xerostomia, particularly where the salivary glands are in the path of the radiation beam, mucositis due to atrophy of the oral mucosa, and severe oral pain from mucositis. Long-term effects include microdontia, hypocalcification, short and blunted roots, and delayed tooth eruption. Patients undergoing hematopoietic stem cell transplantation are at risk for oral fungal and herpes simplex virus infections during the initial engraftment and reconstitution period. Allogeneic transplants further predispose a child to oral graft-versus-host disease, which can cause ulcerations, erosive lesions, or whitish reticulations affecting various oral soft tissues.

Preventive Measures

Dental caries affects C-SHCN for reasons that are uniquely related to their medical condition. The long-term use of many medications is associated with increased caries risk as some of these contain sucrose as a sweetener. Likewise, the frequent consumption of supplemental nutrition drinks that are typically high in carbohydrates significantly increases the risk for dental caries. Simple preventive steps such as rinsing with fluoridated water or a fluoridated mouth rinse, and/or tooth brushing with fluoridated toothpaste after each medication or supplemental nutrition intake lowers caries risk in such patients. The prescription of sugar-free alternatives for medications is recommended as a preventive measure.

The susceptibility of C-SHCN to periodontal diseases increases with difficulty performing oral hygiene due to a child’s oral aversions, limited mouth opening, or erratic body movements. Parents may also wrongly choose not to brush their child’s teeth believing it to be unnecessary since the child takes no foods my mouth. G-tube fed children typically exhibit increased calculus build-up due to the lack of mechanical stimulation associated with oral feedings, increasing their risk for periodontal disease.

Preventive Measures for the Oncology Patient

It is imperative that a dentist knowledgeable about pediatric oncology evaluate children with cancer soon after diagnosis. The aims are to (1) develop a dental treatment plan in collaboration with the oncologist prior to cancer therapy, (2) educate the patient and caregivers about the importance of good oral hygiene, and (3) remove all existing and potential sources of dental infection (eg, abscessed teeth, extensive caries) before the child becomes neutropenic from chemotherapy.

Preventive strategies aimed at reducing oral complications from cancer therapy include reduction of refined sugars, fluoride therapy, mucositis prevention, and patient education. Meticulous oral hygiene reduces the risk for severe mucositis. In children receiving radiation therapy, customized fluoride applicators and artificial saliva are used in combination with regular follow-up visits to minimize rapid and extensive destruction of teeth due to xerostomia.

Dental Treatment Considerations

Indications for Antibiotic Prophylaxis

All dental procedures (even tooth brushing) often result in transient bacteremia. Patients with certain medical conditions are at increased risk for bacteremia-induced infections and require prophylactic antibiotic coverage prior to invasive dental procedures. These include children with cardiac conditions such as heart valves, previous infective endocarditis, repaired congenital heart disease with residual defects related to a prosthetic patch, and unrepaired cyanotic congenital heart disease. For nonvalvular devices such as indwelling vascular catheters and cardiovascular implantable electronic devices, antibiotic coverage is only indicated at the time of placement and possibly 3–6 months afterward. Hydrocephalus shunts with vascular access (ie, ventriculoatrial, ventriculocardiac, ventriculovenous) require antibiotic prophylaxis to minimize risk for infection from dental procedures, whereas the nonvascular type (ventriculoperitoneal) does not.

Antibiotic prophylaxis is generally not indicated for dental patients with pins, plates, screws, or other orthopedic hardware that is not within a synovial joint. Likewise, most patients with total joint replacements do not routinely require antibiotic prophylaxis except for the early postsurgical period (6 months).

For immunocompromised patients, the absolute neutrophil count (ANC) is important for the dentist because of the risk for systemic sepsis from dental procedures. The AAPD guideline indicates for neutrophil levels above 2000/mm³ antibiotic prophylaxis is not indicated. Between 1000 and 2000/mm³, prophylaxis is subject to the clinical judgment of the dentist, the patient’s health status, and the planned procedures. Both the dentist and physician should discuss and plan the need for antibiotic prophylaxis in these unique circumstances.

Management of Bleeding Disorders

Oral surgical procedures on any child with a bleeding disorder should be planned in a coordinated approach between the child’s hematologist and dentist. Patients with mild bleeding disorders (eg, mild von Willebrand’s disease) can be treated in the ambulatory dental setting with local hemostatic measures such as topical hemostatic agents (eg, Gelfoam, thrombin). Patients with severe coagulation disorders (eg, severe hemophilia A and/or Factor VIII antibodies) requiring dental surgery should be admitted to a hospital. Preoperative planning includes prescription of antifibrinolytic medications such as ε-aminocaproic or tranexamic acid to minimize postoperative oral bleeding. Intra-operatively, the placement of topical hemostatic agents within tooth sockets and additional sutures immediately following extractions improves clot formation.

For patients receiving anticoagulation therapy, dosage reduction before dental surgery is generally not recommended as the risk of embolism outweighs the risk for bleeding complications. In these instances, the dentist should consult with the hematologist to obtain the most recent INR and discuss the most appropriate anticoagulation level at which a dental procedure can occur. Also, the administration of a “bridging agent” such as enoxaparin in preparation for the planned dental procedure reduces postoperative bleeding concerns while minimizing embolic complications.

Patients undergoing chemotherapy and/or hematopoietic stem cell transplantation are also at risk for intra-oral bleeding. They can experience spontaneous oral hemorrhage, particularly when the platelet count is less than 20,000/μL. Typically, platelet counts greater than 75,000/μL do not require additional measures for dental procedures, while lower levels require pre- and postoperative platelet transfusions.

The pediatric dentist is involved in the timely detection of orthodontic concerns in the mixed or permanent dentition and facilitates appropriate referral to an orthodontist for correction of the malocclusion to promote normal growth development of jaws and teeth. For any child with a cleft palate or other craniofacial growth disorder, referral is indicated when maxillary permanent incisors are starting to erupt and an alveolar bone graft is contemplated.

The orthodontic evaluation to detect a malocclusion usually involves detailed examination of the craniofacial and intra-oral structures. The extra-oral analysis includes assessment of head shape, facial form, and mandibular growth pattern. The intra-oral analysis includes assessment of the sagittal relationship between the permanent first molars, canines, and incisors of the maxilla and mandible. Discrepencies between these teeth in the coronal and sagittal planes can result in crossbites involving the anterior and posterior dentition. The clinical assessment is typically coupled with a radiographic evaluation utilizing panoramic or cephalometric radiographs. The radiographic assessment provides supplemental detailed information regarding the malocclusion by assessing the relative position of the jaws with respect to the cranial base and teeth, as well as the growth pattern of the mandible.