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Oral Health

Oral Health. Evelyn Berger-Jenkins, MD. Learning Objectives. Recall normal pattern of primary and secondary tooth development Identify common non-tooth related pathology in the oral cavity Include screening for caries in well child care, and establish prevention strategies with parents

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Oral Health

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  1. Oral Health Evelyn Berger-Jenkins, MD

  2. Learning Objectives • Recall normal pattern of primary and secondary tooth development • Identify common non-tooth related pathology in the oral cavity • Include screening for caries in well child care, and establish prevention strategies with parents • Be aware of some of the evidence base around controversial oral health issues

  3. Case #1 • ‘A’ is a 3-week old, ex-FT boy with no significant peri-natal complications. He comes today for his first well-child visit. His mother had no complaints, but on exam you notice the following:

  4. 3 week-old

  5. Natal teeth • Usually “normal variant”, but can be associated with certain syndromes: • Ellis van Creveld • Hallermann-Streiff • Jadassohn-Lewandowski • What to do? • X-ray • Observe • Remove if supernumery, feeding problems or loose

  6. Case #2 • ‘B’ is A’s twin sister. She has no natal teeth, but mom is concerned about this other bump in her mouth

  7. Other “bumps” in the mouth…  Mucocele Ranula 

  8. Other “bumps” in the mouth…

  9. Other “bumps” in the mouth…

  10. Case #3 • ‘C’ is a 4 month-old girl who presents because her mother noticed “some white stuff on her tongue”. What is your differential diagnosis?

  11. White stuff on tongue?

  12. Case #4 • ‘D’ is a 10 month-old healthy girl presenting for well-child care. Her father complains that she’s been taking less formula and wonders if it’s because she’s teething. She had eruption of her lower central incisors at 6 months. He asks you when she will get her two front teeth?

  13. Normal tooth eruption

  14. Permanent teeth

  15. Case #5 • ‘E’ is an 18-month old boy with no significant past medical history. He presents with fever to 101.2 x 2 days. He had mild nasal congestion yesterday. Mom asks if his fever could be due to teething?

  16. Does teething cause fever? Tighe M et al. Archives of Disease in Childhood. 2007;92:266

  17. Does teething cause fever? • Review of the evidence • Mostly poor quality studies, i.e. retrospective or relied on parent report • Two prospective studies found an association between increased temperature and the day of tooth eruption +/- 1 day. • Bottom line • Infants with fever > 38.5, or with temperature 38-38.5 on days other than the day of tooth eruption +/- 1 day should be evaluated for other sources of fever. • Those presenting with low-grade fever (< 38.5) during this window may be monitored conservatively if well appearing. Tighe M et al. Archives of Disease in Childhood. 2007;92:266

  18. Case #6 • ‘F’ is a 2 year-old girl with mild speech delay. Her mother is concerned that her speech delay is due to her “tongue tie”. What do you tell her?

  19. Ankyloglossia • Prominent lingual frenulum occurs in ~3-5% of children • Complications may include • Feeding (breastfeeding) difficulties • Articulation problems

  20. Ankyloglossia & speech delay? • Review of the evidence • No evidence for ankyloglossia and speech/language delay • Moderate evidence for moderate-severe ankyloglossia and articulation problems • Lingual frenulum will recede by 6 years of age in majority of children  therefore may observe conservatively

  21. Case #7 • ‘G’ is a healthy 3 year-old boy presenting for WCC. Mom has had trouble getting him to sleep throughout the night b/c he still wakes for his bottle. On exam you are presented with the following:

  22. Dental caries

  23. Dental caries - Epidemiology • The MOST common chronic disease in children • 18% in 2-4 year olds  67% in 12-17 year olds • Higher in certain ethnic groups • Common in < 3 year-olds due to • Primary teeth are thinner than permanent teeth • Teeth that erupt 1st are less protected by saliva

  24. Dental caries - Pathogenesis

  25. Extrinsic factors Dyes in foods (coffee), cigarettes… Medications (tetracyclines, anticholinergics) Metals (iron, lead) Trauma Intrinsic factors Hyperbilirubinemia Poryphyria Differential diagnosis of discolored teeth Tetracycline discoloration

  26. Dental caries - Management • Remove plaque and decayed teeth • PREVENTION, PREVENTION, PREVENTION! • Oral hygiene • Limit substrate (carbohydrates) • Fluoride

  27. Prevention – oral hygiene

  28. Preventive – Dental Home • Beginning at 6-mo pediatricians should: • Assess mother’s oral health. • Assess oral health risks* • Examine mouth/teeth and recognize signs/symptoms of caries. • Assess child’s exposure to fluoride. • *Send high-risk patients to dentist sooner

  29. Case #7 continued… • Mom asks if this could have been prevented if she had given him a vitamin. Her friend is giving her child supplemental fluoride, but you never prescribed this for her. Why?

  30. Fluoride • Anti-cariogenic • Decreases demineralization by • combining into & strengthening enamel • decreasing production of acid from bacteria • Present in 2/3 of all US public water supplies (http://apps.nccd.cdc.gov/MWF/Index.asp) and most toothpastes • Supplement if low fluoride levels in water supply, or child doesn’t drink water

  31. Fluoride supplementation

  32. Case #8 • You’re in the ED and are presented with ‘H’, a 5 year-old boy who comes in with his front tooth in a cup of salt water. It fell out when he was hit in the face during a baseball game.

  33. Dental trauma • Were these likely his primary or secondary teeth? • What should you do with the patient? The tooth?

  34. Dental trauma - management • Don’t forget to assess for head trauma • Call OMF surgery early • Utility of preserving the avulsed tooth? • Avulsed primary teeth should NOT be reimplanted • Avulsed permanent teeth should be re-implanted STAT (before 15 minutes) or stored in cold milk until they can be restored

  35. Case #9 • ‘I’ is a 12 year-old girl with no significant past medical history. She sucks her thumb, and her mother is asking your opinion about obtaining braces for the following problem:

  36. Malocclusion • Causes: • Hereditary • Behaviors (bottles, pacifiers and thumb sucking esp. beyond 5 yrs.) • Treatment: • Mostly cosmetic • Orthodontist referral best if early

  37. Case #10 • ‘J’ is a 14 year-old girl who is preparing for her quinceañera. She asks you whether there is any “downside” to using teeth whiteners, and whether you could recommend a whitening method. What do you tell her?

  38. Tooth whiteners? • Lee SS et al. • Recent review of tooth whitening in children • Conclusions: • 30-50% of patients experience gingival irritation (increased in children) • Excessive peroxide exposure can cause pulpal/root damage esp. in < 18 year olds • Whitening during mixed dentition will result in uneven results Lee SS et al. Pediatric Dentistry. 2005 Sep-Oct;27(5):362-8

  39. References • MAIN: • Website AAP Health Topics, Oral Health: www.aap.org/healthtopics/oralhealth.cfm • Preventive Oral Health Intervention for Pediatricians. Pediatrics 2008;122:1387-1394 • OTHER: • Natal Teeth A Review: J Natl Med Assoc. 2006 Feb. 98(2):226-8 • Delayed Tooth Eruption: Am J OrthodDentofacialOrthop. 2004 Oct. 126(4):432-45 • Fever & Teething: Archives of Disease in Childhood. 2007. 92:266 • Ankyloglossia: J Paediatr Child Health 2005 May-Jun. 41(5-6):246-50 • Fluoride content in various water sources: http://apps.nccd.cdc.gov/MWF/Index.asp

  40. The End – SMILE!

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