Diane L. Markowitz, DMD, Ph.D.
Rowan University
Glassboro, New Jersey
Jennifer A. Markowitz, MD
Massachusetts General Hospital
Boston, Mass.
PRE-TEST QUESTIONS (Annotated Answers at the bottom)
Q1: T or F. All children should receive 1 mg. fluoride alone or in a multi-vitamin, given daily.
Q2: Best answer. Which of the following is not associated with dental caries in children?
A. allowing the infant to fall asleep with a bottle filled with milk, juice or any sweetened beverage.
B. poor oral hygiene.
C. excessive protein intake in pregnant women.
D. enamel hypoplasia.
Q3: T or F. Oral symptoms of systemic disease are late findings.
Q4: T or F. Periodontal disease is found in adults only.
Q5: Plaque is:
A. glycoproteins and mucopolysaccharides.
B. Oral bacterial colonies and their acidic secretions.
C. The detritus of unswallowed food.
D. All of the above.
OBJECTIVES
At the conclusion of this section, residents will be able to:
1. Develop a routine protocol for examination of the child's mouth.
2. Recognize the appearance of healthy teeth, gingivae and oral mucosa.
2. Identify caries, periodontal disease, aphthous ulcers and oral mucositis.
3. Discuss mechanisms for dietary effects on oral disease and strategies for encouraging good diet and oral hygiene.
4. Recognize and treat common oral effects of systemic disease or immune suppression.
5. Learn when to refer patients to pediatric dentists and how to make the dentist a partner in the treatment of a child's systemic disease.
6. Overcome institutional, governmental and pediatric practitioner reluctance to treat oral disease in children.
FACILITATOR PREPARATION
For this section, the facilitator should begin by reviewing the section in Pediatric Nutrition Notes. See also:
(1) American Academy of Pediatrics Committee on Nutrition, (2003-2004) Pediatric Nutrition Handbook, USA: American Academy of Pediatrics.
(2) Markowitz DL, Oral health care for the disadvantaged child, 1993. In Karp, RJ. Malnourished Children in the United States. (pp. 168-173). New York: Springer Publishing.
(4.) A particularly useful source of information is: Touger-Decker R, Sirois DA and Mobly CC (eds.), 2005. Nutrition and Oral Medicine. Totowa, New Jersey: Humana Press
INTRODUCTION
The relationship between nutrition and oral health is reciprocal. Oral disease can alter nutritional status which, in turn, may significantly affect general health. Conversely, the pediatrician needs to be aware of the effects of poor general health and impaired nutritional status on oral disease. In order to maintain the patient's well-being, the pediatrician can and should become an active participant in ensuring the patient's oral health, both with direct advice to parents on nutrition and oral hygiene and by referring to and consulting with a pediatric dentist.
The oral health of any child begins with gestation. At six weeks post-conception, tooth buds begin to form within the mandible and maxilla, laying down enamel first and then dentin. At birth, more than 80% of the deciduous enamel is already formed. Thus, any insult from poor maternal health or nutrition or from teratogens may affect both the form of the developing teeth as well as their susceptibility to caries. Immune suppression, whether primary as in HIV or secondary resulting from treatment, permits overgrowth of the mouth's natural flora and increases the child's susceptibility to demineralization of enamel (the first step in caries development), periodontal disease
and oral mucositis.
A thorough oral examination should become part of each pediatric examination. Concurrently, caregivers and, when appropriate, children should be questioned about dietary and hygiene habits. The examination begins with the lips. Dry, cracked lips are a frequent finding not only when the child is dehydrated but also when salivary flow is insufficient. Other factors such as an inability to close the lips when the mouth is at rest or mouth breathing may lead to a drying of saliva and increased mineral precipitation from saliva into plaque that adheres to the teeth. Next, pull the cheeks laterally and examine the oral mucosa. Mucosa should be smooth, pink and wet. With a gauze pad, wipe the area around Stenson's duct (the parotid duct) and determine that saliva continues to be secreted from the duct. Lift or ask the patient to lift the tongue and blot the sublingual salivary ducts with gauze and examine them to determine their patency. Carefully, survey the gingiva. It should be stippled, pink (and/or pigmented in darker-skinned children) and should lay flat against the teeth). Finally, examine the teeth under bright light. If you haven't already done so, familiarize yourself with the normal surface anatomy of both the deciduous and permanent dentitions first. Teeth should be intact, with enamel at the surface that is moderately translucent. Except
for the normal buccal grooves in mandibular molars and lingual groves in maxillary molars, there should be no pits or troughs in the buccal (facing the cheek), labial (facing the lips), palatal or lingual surfaces.
Parents and children capable of answering should be questioned about their diet and oral hygiene habits, including flossing. Mothers of infants should be asked to detail the child's feeding habits and whether or not they clean the child's teeth.
Children with healthy mouths have few problems eating and drinking. By eliminating oral pain and infection, the practitioner reduces the need for dietary supplements, pain medication and antibiotics. Pediatricians are integral members of the oral health care team, providing advice for new parents, medical and dietary treatment as needed and referral to pediatric dentists.
The following discussion encompasses the major symptoms
of oral disease.
The most frequent childhood problems in the mouth are caries, periodontal disease, mucositis and aphthous ulcers. Early exfoliation of the deciduous dentition is uncommon, but delayed eruption of the permanent dentition is not. Caries and periodontal disease may be caused by poor diet and oral hygiene, but both may be exacerbated by systemic conditions. The child who is unable to breathe through the nose or whose lips are not closed at rest is at increased risk of caries and/or periodontal disease, because plaque on the teeth is less likely to be washed away by saliva. Oral mucositis is a non-specific inflammation of the oral mucosa that may have systemic or exogenous causes. At the time of this writing, the etiology of aphthous ulcers (Fig.1), in children is unknown but they may occur more frequently with certain types of systemic conditions such as Crohn's Disease as well as with some medications.
Figure 1.
Fig. 1. Aphthous ulcer.
Virginia Commonwealth University Library
Dental caries. The natural flora of the mouth include several organisms that may, if left to multiply unchecked, cause caries. The most frequent culprit is Streptococcus mutans , though lactobacilli and actinomycetes may play a supporting role. All of them thrive in plaque. Bacterial excreta are acidic and will begin to demineralize adjacent enamel if their colonies are left undisturbed for more than 24 hours. Eventually, the demineralization process results in a microscopic perforation into the dentin. Since dentin has a higher organic and lower mineral content than enamel, it presents less of a barrier to bacterial progression. If the decay reaches the pulp of the tooth, the pulp may become inflamed, causing toothache. Finally, the pulp becomes necrotic and the necrotic tissue may reach the supporting bone, causing an abscess.
Plaque is an accumulation of food debris, mucopolysaccharides from saliva and bacterial colonies that flourish in its viscous substrate. It forms throughout the day and overnight but is easily brushed and flossed away. However, it remains on the teeth in patients with poor oral hygiene. Any systemic disorder that diminishes salivary flow also may increase the risk of dental caries or periodontal disease by causing plaque to become dried out and thus more adherent to the teeth. Anticholinergic drugs or botulinum toxin A (given to diminish drooling in cerebral palsy) diminish salivary flow. Mouth breathing, common in many children with nasal allergies, dries saliva quickly, promoting the adherence of plaque to the teeth. Periodontal disease and early exfoliation of teeth. Periodontal disease is an inflammation of the supporting tissues of the teeth, characterized by persistent inflammation of the gingiva with swelling (Fig. 2), loss of the ligamentous attachment of the cementum to the bone and progressive migration of the alveolar bone toward the apex of the tooth. In both adults and children, the major cause of periodontal disease is poor oral hygiene, with accumulations of plaque and calculus on the teeth, around and beneath the gingiva. Periodontal disease may begin early in juvenile diabetics, causing all of these symptoms. Nevertheless, it is uncommon for children to lose teeth to periodontal disease.
Figure 2. Gingitivis secondary to poor oral hygiene
Courtesy of Dr. Arthur Nowak
Systemic complications and oral disease. Dental caries, periodontal disease and dental abscesses may lead to bacteremia, requiring a course of antibiotics. In turn, systemic conditions or procedures such as HIV infection, sickle cell anemia, organ transplants and chemotherapy suppress the immune response and increase the risk of bacterial damage to both teeth and gingiva.
Enamel defects. If the child is acutely ill or undernourished, - whether for endogenous or exogenous reasons - ameloblastic activity (the development of the enamel-forming cells in the tooth bud) may cease entirely in the developing teeth. Formation of the enamel resumes when the insult is eliminated. When the tooth has completed its development, this phenomenon may be observed in a depressed horizontal line or a series of pits in a horizontal line on the tooth crown. This condition is known as enamel hypoplasia. Hypoplastic enamel is also hypomineralized (Fig. 3), and the risk for dental caries is increased, particularly when it occurs next to the gingival where plaque frequently accumulates. Bilateral enamel hypoplasia in developing teeth may follow severe nutritional deficiencies, high fevers, sickle cell anemia, malaria, prematurity, neonatal hypocalcemic tetany, chemotherapy or hypoparathyroidism. Prolonged orotracheal intubation in premature infants has been associated with enamel defects in the anterior deciduous dentition. Preterm delivery and low birth weight are significantly associated with enamel hypoplasia. Hypoplastic enamel is more likely to become carious.
Fig. 3. Hypoplastic enamel.
Creighton University School of Dentistry
Pediatric Dentistry Clinical Photos
Anticipatory guidance. Calcium and phosphates, precipitated from the saliva, continue to be deposited in the enamel of erupted teeth until adulthood. Thus, the more recently erupted the tooth, the more vulnerable it is to oral bacteria and especially to sugar. Naturally-occurring pits and fissures in teeth may be effectively prevented from decaying by the application of a pit and fissure sealant, applied in a dental office. The following measures have also proven effective in promoting healthy teeth and gums.
Diet: The role of any type of sugar in promoting caries needs to be explained to the parent. The longer the sugar remains in the mouth (and this includes the refined carbohydrates in chips, pretzels and baked goods) the more dangerous it is. Lollipops, gummy candies, sucking candies and sweetened, carbonated beverages are the worst - though certainly not the only - offenders. Substitution of fresh fruits and vegetables is often unsatisfactory for a variety of reasons, not the least of which is the continuing presence of cariogenic foods in the home. A change in the child's diet must become part of a change in the family's diet. No child can be convinced of the edibility of foods that the adults do not eat. Suggest ways to gradually incorporate fresh fruits and vegetables and unsweetened dairy products into the diet or have a nutritionist consult with the family. Abrasive foods - such as raw vegetables - also disrupt plaque, thus decreasing the likelihood of demineralization. Eventually, the volume of this good food should fill up the child and, if sweetened foods are not available in the home, the child will be less tempted to eat them.
Finally, no child should be put to bed with a bottle filled with anything but plain water. Even unsweetened fruit juices can cause tooth decay when salivary flow diminishes at night. During the day, no child should be drinking more than 1 or 2 glasses of fruit juice, while the limit for infants is 4-5 ounces. No child should be drinking carbonated beverages, eating candy (except on a special occasion) or pastries
between meals.
Oral hygiene: Deciduous teeth should be cleaned by the parent as soon as they erupt. Wiping them with a gauze pad is a good way to clean them. Soon after teeth begin to erupt, parents should begin brushing them gently with a soft toothbrush after meals. This gets the child used to the feel of the toothbrush in the mouth. No dentifrice should be used, as the child will merely swallow it. When the child wants to do it himself, he or she should be encouraged, watching as the parent brushes his/her own teeth. Children should be supervised while brushing at least twice per day until the parent is certain that the child is competent to do a good job and spot-checked thereafter. Children with sufficient manual dexterity - usually not before age 7 - should be encouraged to floss at least once per day. Again, children will do what they see the parent doing.
Fluoride: Once children are able to spit, they should brush with a fluoride dentifrice. The American Dental Association seal of approval on the box identifies a tooth paste with the optimum level of fluoride. Fluoride promotes dental remineralization and retards demineralization. There is currently a vast amount of research demonstrating that optimum levels of fluoride in the diet dramatically reduce the prevalence of dental caries (tooth decay). Fluoride is found in most liquid infant formulas but is absent from bottled water or may be intentionally filtered out of the home's drinking water by parents under the mistaken apprehension that it is harmful. The following are optimum daily levels of ingested fluoride for infants and children:
TABLE 1. Daily Fluoride needs through childhood
AGE Daily Fluoride needs
Birth to 6 months 0.01 (Supplementation is unnecessary < 6 months of age)
7 to 12 months 0.5 mg
1 to 3 years 0.7 mg
4 to 8 years 1.0 mg
9 to 13 years 2 mg
14 years to adulthood 3 mg
In areas where the water is fluoridated optimally, no supplementation is necessary. Check with your local public health department or water utility to determine the concentration of fluoride in the drinking water. This information also can be accessed at the following CDC website: http://apps.nccd.cdc.gov/MWF/Index.asp. If the total levels are adequate, further supplementation with fluoride vitamins may result in yellow or white opacities in tooth enamel - a condition known as fluorosis. Fluorosis does not result in tooth decay, but can be quite unattractive (Fig. 3).
Figure 4.
Fig. 4. Dental fluorosis (unrelated to edematous gingiva secondary to poor oral hygiene and mouth breathing)
Visiting the dentist: At the end of the first year, the child should be referred to a dentist for the first checkup. This recommendation is less for the immediate benefit of the child than for the long-term effects of educating caregivers. When the techniques and advantages of brushing the child's teeth with a fluoride dentifrice and feeding the child a diet low in sucrose and high in fiber are explained, there is a demonstrable decrease in the number of carious lesions later in the child's life. At age 3 and older, children should have a dental examination and cleaning every 6 months.
Oral habits:
Thumb sucking is entirely normal but should be discouraged nevertheless, particularly in the daytime. Vigorous, constant thumb sucking results in a high, arched palate and sometimes a cross-bite (maxillary molars fit inside the mandibular molars) or an anterior open bite (anterior maxillary and mandibular teeth do not approximate). These conditions will require orthodontic correction. Explain to the parent that when the child sucks the thumb, the cause should be investigated and corrected: often children are tired, fearful or hungry when they suck their thumb. Most children will stop sucking their thumbs when they are enrolled in school, if not before. However, offering a pacifier to a child over the age of 6 months is not recommended. The constant sucking, even with more anatomically correct pacifiers, will produce the same eventual effect as thumb sucking.
The average teen now gets ~11% of his daily calories from soda. Dental erosion is being seen with increasing frequency in children, and the proximate cause in most children is excess intake of carbonated soda which is weakly acidic. Severe erosion on the lingual and palatal surfaces of teeth also can be the first sign of binging and purging behavior in teenagers or may occur with severe gastroesophageal reflux.
Oral signs of systemic disease:
Juvenile periodontal disease may be exacerbated by cyclic neutropenia, Kostmann syndrome, Papillon-Lefèvre Syndrome, Haim-Munk Syndrome, hypophosphatasia, acute lymphoblastic leukemia, defective chemotaxis or adhesion of white blood cells or poorly controlled diabetes. Any process that diminishes the immune response, increases the deposition of plaque and adherence of calculus or promotes gingival swelling is likely to cause periodontal disease. Children who have any of the muscular dystrophies or who are comatose, intubated or require feeding with a gastrostomy tube for long periods of time are at particular risk. The treatment for glycogen storage disease promotes the deposition of plaque and calculus and will eventually increase susceptibility to periodontal disease if excellent oral hygiene is not practiced.
Serum glucose, as well as salivary glucose, may be elevated because of uncontrolled diabetes or insulin-dependent diabetes mellitus. This can also occur in the pre-diabetic state seen in many obese children. The teeth, particularly the crowns next to their gingival sulci, thus are bathed constantly in saliva with an elevated glucose level. By itself, this does not have an effect on the risk for caries, though it does affect susceptibility to periodontal disease. However, in concert with poor oral hygiene and periodontal disease, the risk for caries is slightly increased. Children with Type I diabetes mellitus have been found to accumulate calculus slightly faster than do non-diabetic controls, and this increases the risk for periodontal disease.
One of the sequelae of chronic kidney disease is the destruction of Vitamin D. Vitamin D is required for the metabolism of calcium which, in turn, is essential in the development of healthy bones and teeth. Circulating Vitamin D also may be inadequate with mild to moderate hepatic failure, fat malabsorption syndromes, and in children taking glucocorticoids or medication for seizure disorders.
Acute lymphoblastic leukemia often results in spontaneous gingival bleeding and ulcerations, as does a deficiency of vitamin K. The patient should be kept comfortable by prescribing topic analgesics (as long as the child can spit), acetaminophen and gentle cleansing. Unfortunately, the oral problems are unlikely to improve until the systemic disease does.
Under extreme stress and poor diet, any child (or adult) can develop acute, necrotizing, ulcerative gingivitis (ANUG). ANUG is characterized by necrosis of the gingiva between the teeth that is then covered by a grayish membrane. This tissue is intensely painful, bleeds easily and the patient has a distinctive halitosis. Teenagers are particularly apt to develop this condition around exam time, but any child whose
immune system is compromised may suffer from ANUG. A pediatric dentist will treat this, but it is extremely important that the patient maintain excellent oral hygiene (in spite of bleeding) and diet, as well as taking a multivitamin, multimineral preparation (because chewing is painful). Megadoses of vitamins and minerals have not been shown
to shorten the course of ANUG.
Oral signs of nutritional deficiencies. [see also below for guide to child's nutrition and oral health]
These include lingual filiform papillae, glossitis and atrophy, or thinning, inflammation and ulceration of the oral mucosa may not be pathognomic. Instead, they may result from a variety of nutritional deficiencies - some primary, some secondary to other conditions. Nutritional deficiencies may also predispose the child to candidiasis and secondary staphylococcal infections.
Figure 5.
Fig. 5 glossitis, geographic tongue.
Creighton University School of Dentistry
Pediatric Dentistry Clinical Photos
Table 2:
Oral mucositis. This condition usually occurs on the non-keratinized oral mucosal surfaces and is characterized by erythema, edema and ulcerations. There may also be a false membrane consisting of exudate and fibrin and enlarged local lymph nodes. Children suffering from oral mucositis are at risk of developing opportunistic infections or supervening herpetic, bacterial and fungal infections, any of which may become systemic. Systemic diseases or treatment for them that may cause oral mucositis may include celiac disease, thrombocytopenia, myoablative therapy in preparation for bone
marrow transplants, acute graft-vs.-host disease, chemotherapy, and others. Children undergoing chemotherapy have suppressed immune systems, diminished salivary flow and will often find brushing and flossing painful, leading to poor oral hygiene, nutritional deficiencies and an increased risk of dental caries and other oral infections. Nursing staff and family members should be urged to brush and floss the child's teeth 3 times daily, gently massaging the gums after administration of appropriate amounts of acetaminophen to reduce pain. Some bleeding is to be expected. The benefits of good
oral hygiene and diet far outweigh the risk of transient and treatable bacteremia. In addition to good oral hygiene and the necessary nutritional supplementation, topical administration of Vitamin E also has been found to be effective in alleviating oral mucositis.
The role of the pediatric dentist.
The ability to eat is key to a child's ability to heal. Oral conditions that make feeding painful directly affect the efficacy of medical treatments. The specialist most able to treat and prevent this is the pediatric dentist, who should be consulted in anticipation of the occurrence of well-known oral complications of medical treatment and disease. When the child is no longer hospitalized, regular examination and treatment by the dentist is essential for the prevention of oral disease. The pediatrician should receive regular reports on the child's progress from the dentist, as would be expected from any medical specialist, and the pediatric dentist should be kept informed of any medical developments by the physician. Records of discussions with parents and children about oral hygiene and diet should be shared among dentists and physicians, so that progress or the need for further encouragement can be assessed.
Table 3. Oral disease, with a differential diagnosis of likely causes and suggestions for treatment . (This is a general guide for the pediatrician on what to look for in the mouth and what it means).
Please Click here to view table.
Maternal nutrition.
During gestation and lactation, and even during the pre-conception period, the development of the teeth may be affected by maternal vitamin and mineral deficiencies. Folic acid diminishes the likelihood of damage to DNA during mitosis, an especially important function during embryogenesis and subsequent development. An inadequate supply, therefore, may interfere with normal growth of the embryo and result in a variety of neural tube defects. Maternal folic acid and Vitamin A deficiency have also been implicated in unilateral cleft lip, with or without cleft palate. For at least one month before conception as well as during pregnancy and lactation, women should take 800 mcg of folic acid daily. Maternal deficiencies of Vitamins A, D and C have also been implicated in disturbances of dental development. Deciduous teeth are largely mineralized before birth as are the cusp tips and incisal edges of the permanent first molars and incisors. Of mothers who were Vitamin D deficient during pregnancy, in one study, 80% of their infants were deficient at birth.
Protein deficiencies, while infrequent in the U.S., do occur. Protein deficiencies can restrict the size of the developing sublingual glands. Any subsequent reduction in the amount of salivary flow will increase adherence of plaque to the teeth. Secretions of the parotid gland are reduced by deficiencies in vitamins A, D and zinc and iron.
The child's nutrition and its relation to oral health.
Any process that affects the oral mucosa will also be systemic, although oral symptoms may be seen first. Changes in the oral mucosa can signal deficiencies of iron, riboflavin, niacin, folic acid, protein and vitamins B12, C and K.
Vitamin D deficiency is very common and has been found in 48- 55% of children tested in several studies. The frequency is higher in children with dark skin and during the winter. Children with insufficient Vitamin D are at risk of developing hypomineralized dental enamel, increasing susceptibility to caries. [see modules on Calcium and rickets as well as pediatric Nutrition Notes, Part I]
Calcium deficiency is very common and often coupled with Vitamin D and phosphate deficiency. The calcium in enamel and dentin is virtually inert and cannot be mobilized for use elsewhere in the body. However, calcium deficiency during dental development may result in enamel hypoplasia (see above) and has also been implicated in periodontal disease. Low serum calcium has not been shown to affect the deposition of calculus but may decrease remineralization of enamel.
Vitamin C deficiency may promote gingival bleeding and is a risk factor for periodontal disease when combined with poor oral hygiene. The evidence of a beneficial effect on gingival health for megadoses of vitamin C is contradictory and inconclusive at this time. The child who eats few fruits and vegetables often has a diet high in fermentable carbohydrates, anyway, which raises the risk of caries.
A note about possibilities for instruction of parents
Telling a parent to provide better nutrition for the child and to limit the child's sugar intake is easy. But the parent may have a limited budget, a sick and cranky child, his or her own problems, those of other children or relatives, limited access to cooking facilities or a neighborhood where fresh fruits and vegetables are expensive and of poor quality. Before telling a parent what to do, find out what the impediments would be to implementing your suggestions. Anything you can do to alleviate those problems will increase the likelihood that your dietary advice will be followed.
CASE STUDY - PART I
Alan is an 18-month old boy who is brought into the clinic for a well-child exam by his guardian, the child's paternal aunt, Letitia Peters, who has been caring for him for the past year. Ms. Peters reports that Alan has been more than usually fussy for the past 2 weeks, whimpering constantly for no apparent reason and refusing cold or hot food and liquids. She has been allowing him ad libitum access to room-temperature milk in his bottle since he came to stay with her. His physical exam is unremarkable and his temperature is normal. An oral examination reveals that there are white opacities near the gums on his anterior teeth and horizontal troughs on his first deciduous molars.
BACKGROUND MATERIAL for preceptors
Alan was removed from his home and drug-addicted mother who was undernourished during pregnancy, resulting in enamel hypoplasia of his deciduous teeth. Since he's been crying frequently since he was placed with her - and his aunt has no experience with children - she's been allowing him to go to bed or to sleep with a bottle of milk. This is causing demineralization of his anterior teeth (Fig. 6) and it's quite likely the dentin has already been penetrated by S. mutans (the major cause of tooth decay).
Figure 6.
Fig. 6. Hypomineralized enamel, early caries.
Courtesy of Dr. Arthur Nowak
The reason he refuses both hot and cold food and drink is because his decayed teeth are very sensitive. This child is at serious risk of developing nursing bottle caries (Fig. 7) and should be seen by a pediatric dentist immediately.
Figure 7.
Fig. 7. Severe nursing bottle caries.
Group Exercise #1:
Preceptors- Before continuing, ask the students/residents what, if anything, about the oral findings is significant.
Q1: What kinds of questions would you ask Ms. Peters?
A1: Had you visited your niece before in the home? Was Alan always this cranky? Did your niece put Alan to bed with a bottle? If the answer is yes, reinforce Ms. Peters' perception of herself as a better caregiver by explaining what Alan's mother was doing wrong. If no, explain why putting a child to bed with a bottle is detrimental to his health. In either case, emphasize that the marks you show her on his teeth are cavities and must be treated immediately.
Q2: What is the cause of this condition?
A2: Putting the child to bed with a bottle filled with any type of juice, powdered drink (such as Kool-Aid), soda or milk. Frequent use of a sippy cup with any of these liquids may have the same effect. In some cultures, putting honey or karo syrup in the bottle (with water) is thought to soothe a fussy child. This is a terrible idea.
Q3: What is the risk of failure to treat this condition?
A3: Pain, discontinuation of feeding, infection, damage to developing permanent teeth.
Q4: How do you convince the parent or guardian to stop doing this?
A4: First parents must be convinced of the value of retaining healthy deciduous teeth. Many parents believe that, since baby teeth fall out, they are not needed. Emphasize that even baby teeth are necessary for the child to eat and grow. Explain that permanent teeth grow beneath baby teeth and that infected baby teeth will cause damage to the permanent teeth.
CASE STUDY - PART 2
Sara is a 12 year old girl with acute myelogenous leukemia, who is seven days into conditioning for a bone marrow transplant. She has developed oral mucositis and is unable to tolerate oral feeding.
Q5: What kind of dental care is appropriate for Sara during this time?
A5: Sara's teeth should be gently brushed on a regular basis. A mouthwash containing viscous lidocaine may make this more tolerable. Regular use of Peridex (chlorhexadine: a mouthwash) will control the bacterial activity in Sara's mouth (but her family must be warned that her teeth may be stained black, though the stain can be removed by the dentist). Her immunosuppression and impaired mucosal integrity do put her at risk for bacteremia, and thus prophylactic antibiotics may be warranted during this period.
Q6: Should Sara receive any enteral nutrition during this period?
A6: Yes, it is very important that her nutritional status be maintained, both for her general and oral health. Nasogastric tube feeds may be necessary in this situation.
CASE STUDY- PART 3
Matthew is a 19 year old boy with Duchenne muscular dystrophy. Due to upper extremity weakness and contractures, he is unable to attend to his own oral hygiene. His parents have tried to brush and floss his teeth, but occasionally notice that his gums are bleeding, and are thus concerned that they may be hurting him by doing this.
Q7: What should you tell Matthew's parents?
A7: Explain to them that the gingival bleeding is the result of periodontal disease, which may be alleviated by proper dental hygiene. The bleeding does not pose a significant health risk to Matthew, and it is most important that they help him to brush and floss. This will help his gingiva to recover, and the bleeding will then resolve.
Here are questions to open discussion related to your home institution:
Question: What institutional practices affect the likelihood that caries, periodontal disease, oral mucositis or aphthous ulcers will be diagnosed in pediatric patients? Will be treated?
For the presenter: what is the protocol in your institution for referral to a pediatric dentist? Who follows up? Are reports from dentists placed in the medical record? Do pediatric residents examine the mouth of hospitalized patients without a report of a problem from nurses or parents?
Question: Do you have opportunities to interface with pediatric dentists to discuss patients?
For the presenter: If there is little or no opportunity at this point, what can the pediatrician do to remedy this situation? Is pediatric dental care even available to patients? Are there dentists in the community willing to provide the necessary advice to new parents, to educate them in proper dental care? Will they see parents during the child's first year? Have students check the phone book for pediatric dentists. Have them divide up the list and each should call several dentists, asking which ones will take a.) Medicaid patients and b.) uninsured patients.
Question: What is the likelihood that referral of a Medicaid or uninsured patient to a pediatric dentist will result in a visit? Consider having your office make an appointment for the patient and request a report from the dentist. Follow up on the report at the next patient visit if unremarkable. If a recommendation for immediate care is suggested,
have your office follow up with the patient's guardian to be certain that an appointment was made and that the child was seen and treated.
For the presenter: What may be the kinds of impediments to educating the parents in the necessity of caring for deciduous teeth? Is your staff trained to emphasize and repeat your recommendations?
ANNOTATED ANSWERS TO PRETEST QUESTIONS
A1. False.
Not all children need fluoride supplements, because sufficient fluoride may already be available to the child through ingested food and water. The fluoride content of the patient's drinking water should be determined before prescribing fluoride supplementation. In some areas, the water has naturally-occurring fluoride. Where this is not the case, the majority of municipalities in the United States add fluoride at 0.7-1.2 ppm in drinking water.
A2. C is the correct answer. There is no evidence that high protein intake during pregnancy creates a corresponding drop in calcium levels and there is no association here with caries in children.
A3. False. In many conditions, oral findings precede obvious systemic illness. Cases in point are halitosis that precedes diagnosis of acute lymphocytic leukemia, oral ulcers in Crohn's disease and thrush in HIV.
A4. False. Children with diabetes have increased susceptibility to periodontal disease. Periodontal disease is characterized by an inflammation of the gingiva surrounding the tooth crowns, apical (toward the root) migration of the gingival attachments from the
crown-root junctions and bone loss around the teeth. The disease presents as red, swollen gums and, in extreme cases, loose teeth. Children frequently have halitosis. Periodontal disease in children also may be idiopathic. In either case, excellent oral hygiene, controlled diet and continuing care and treatment by a pediatric dentist - or a
periodontist - are essential.
A5. D. All of the above. Oral bacterial colonies thrive in the detritus of unswallowed food, bound in the glycoproteins and mucopolysaccharides of saliva and adherent to teeth. When minerals from saliva are deposited in plaque, it hardens and becomes calculus (tartar). Plaque can be removed by brushing but calculus removal requires a trip to the dentist.
