Continuity Clinic

Pediatric Dental Care

Continuity Clinic

Objectives

• Know the general pattern of tooth eruption

• Understand the pathophysiology of the formation of caries and how to prevent

• Know the correct time to refer to a dental specialist

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Tooth EruptionYES, THIS IS A

PACIFIER!

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Eruption of Teeth

• By birth:– ~20 primary teeth are almost completely formed and

hidden in the jawbones

• Eruption of teeth highly variable but….– Primary incisors 6-12 months– Most children have a full set of primary teeth by age 3

years– Adult teeth begin to erupt at age 6 years– Lose primary teeth beginning age 6-7 years until ~12

years

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Primary (Deciduous) Dentition

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Permanent Dentition

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Tooth Eruption – When to worry?

• 25% of normal babies may have delayed eruption of teeth until 4 or 6 teeth appear simultaneously after their first birthday

• No teeth by 14-15 months of age – what is cause?– Normal delay in eruption (Familial delayed eruption)– Hypothyroidism and Hypopituitarism– Vitamin D Deficiency/Rickets– Trisomy 21– Ectodermal Dysplasia– Progeria Syndrome– Albright Osteodystrophy– Incontinentia Pigmenti– Apert’s Syndrome

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Hygiene and Cleaning

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Cleaning/Brushing• AAPD recommends daily cleaning of

infant’s gums before the eruption of first tooth

• From birth to age 1 year recommend using moistened gauze or soft cloth to massage/clean gums

• Use toothbrush only if parents feel comfortable – should start using by 1 year

• DO NOT use toothpaste – risk of fluoride ingestion & fluorosis

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Fluorosis

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Toothpaste

• When should parents start using toothpaste to clean child’s teeth and gums?

• Start around age 2 years

• Use small pea-sized amount

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First Dental Visit

• AAPD recommends first dental visit – Within 6 months of eruption of the first primary

tooth– No later than 12 months of age

• AAPD argues that by later age child may already having poor feeding habits and poor oral hygiene

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Dental Caries

Initial Lesions - White decalcification with beginning enamel breakdown

Late stage lesions - Moderate to severe enamel and dentin destruction

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Dental Caries

• Prevalence of Dental Caries – 5 times more common than asthma– 7 times more common than hay fever

• Caries Rate:– 18% aged 2 to 4 years– 52% aged 6 to 8 years– 67% aged 12 to 17 years

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Risk Factors for Caries

• Poor oral hygiene

• High sugar intake

• Mother with high # cavities

• Enamel defects

• Premature birth

• Special health care needs

• Low socioeconomic status

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Caries and Cavities

Brown cavitations

White lines

Gross cavitations

Douglass et al, AAFP 2004

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Etiology of Caries

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Factor 1: The Tooth

• Susceptibility of teeth varies: age, fluoride exposure, morphology, crowding, nutritional status, and presence of acid

• Enamel is where caries begin– composed mainly of minerals in the form

of hydroxyapatite– Primary tooth enamel thinner than

permanent

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Factor 2: Flora

• Growth of oral acid producing (ie. Streptococcus mutans) determined by: frequency of exposure, substrate available for metabolism, oral hygiene, and fluoride

• Bacteria are transmitted from caregivers/sibs to infant at or before the eruption of the first tooth– bacteria transmitted through saliva avoid pre-

tasting, pre-chewing, and sharing utensils – Family members with caries increase risk for infant

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Factor 2: Flora

• Fluoride:– Promotes remineralization of enamel, and may arrest

or reverse early caries– Decreases enamel solubility– Inhibits the growth of cariogenic organisms, thus

decreasing acid production– Concentrated in dental plaque– Primarily topical even when given systemically

• Widespread use of fluoride has been a major factor in the decline in the prevalence and severity of dental caries

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Fluoride Supplement-if no fluoride in water supply-

<.3 ppm .3-.6 ppm >.6 ppm

Birth - 6 months none none none

6 mo to 3 years 0.25 ppm none none

3 to 6 years 0.5 ppm 0.25 ppm none

6 to 16 years 1.0 ppm 0.5 ppm none

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What about water filters?

• Activated carbon filters do not remove significant anounts of F-.

• Reverse osmosis will remove most of the F-• Ion exchange resin filters will remove F- if the resin is in

basic ( not acidic) form.• Distillation removes most of the F-.• Many home units use more than one process to filter

water.

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Factor 3: Substrate

• Caries is promoted by carbohydrates, which break down to acid– Frequency of sugar ingestion is higher risk

than actual quantity– Nighttime feeding BAD

• Acid causes demineralization of enamel• Saliva inhibits bacterial growth• Unremoved plaque promotes the caries

process

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Other interesting pictures and facts…….

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Thumb-sucking

• A mom brings her 3 year old for a visit because he sucks his thumb at night and she is worried that this will “ruin his teeth.”

• What do you tell her?

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Thumb-sucking

• Most children stop thumb-sucking by age 4 years with no harm done to their teeth

• If still sucking thumb after age 4 years, then check with dentist

• In most cases, don’t need to worry about thumb-sucking until age 6 years when permanent front teeth erupt

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Infant Anomalies

• Natal/neonatal teeth

- Location

- Incidence

- Treatment

- Riga-fede

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Inclusion Cysts

• Epstein’s pearls

• Bohn’s nodules

• Dental lamina cyst

• Treatment

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Conjoined Teeth

• Gemination

• Fusion

• Concresence