Tooth	Age of Eruption
Primary Dentition
Maxillary
Central incisor	7½ months
Lateral incisor	8 months
Canine	16-20 months
First molar	12-16 months
Second molar	20-30 months
Mandibular
Central incisor	6½ months
Lateral incisor	7 months
Canine	16-20 months
First molar	12-16 months
Second molar	20-30 months
Permanent Dentition
Maxillary
Central incisor	7-8 years
Lateral incisor	8-9 years
Canine	11-12 years
First premolar	10-11 years
Second premolar	10-12 years
First molar	6-7 years
Second molar	12-13 years
Third molar	17-21 years
Mandibular
Central incisor	6-7 years
Lateral incisor	7-8 years
Canine	9-10 years
First premolar	10-12 years
Second premolar	11-12 years
First molar	6-7 years
Second molar	11-13 years
Third molar	17-21 years

Adapted from Logan WHG, Kronfeld R: Development of the human jaws and surrounding structures from birth to age fifteen years, J Am Dent Assoc 20:379, 1993.

Managing Teething

Often, teeth pierce the gums without causing any symptoms. However, some children show local symptoms, such as redness and swelling in the oral mucosa overlying the erupting tooth. These symptoms appear a few days before clinical eruption. The child may also show signs of irritation, drooling, and sometimes slight fever.

A great number of folk remedies are used, especially in communities without good access to medical care (Smitherman et al, 2005). Rubbing whiskey on the gums or tying a penny on a string around the child’s neck (creates a potential risk of strangulation) are discouraged, as is using a honey-coated pacifier that might cause tooth decay or introduce botulism. At least one case of methemoglobinemia has been reported in a 6-year-old after the use of Baby Orajel for a toothache (had symptoms of cyanosis, vomiting, lethargy, and tachycardia) (Chung et al, 2010). Overuse of topical salicylates can cause burns.

The Oral Examination

Performing an Infant or Child Oral Exam

An infant’s teeth and oral tissues are examined most easily by placing the child on his or her back on an examining table with the head toward the end of the table. Have the parent restrain the legs and hands. Stand at the head of the table and use a tongue blade or toothbrush as a mouth prop. Use a penlight and intraoral mirror for optimal visualization. Tip the head back to see the upper teeth. The examination table approach is also useful for looking at the teeth of older children. Trying to examine the mouth and teeth with the child sitting in the parent’s lap is not recommended because the provider has to bend over to see the upper teeth, and the crying and movement of the child make visibility very poor.

An alternative for examining a small child is the knee-to-knee approach favored by many dentists. In this approach, the provider and parent sit knee to knee. The parent holds the child facing him or her and then lowers the head into the provider’s lap. The child’s legs are wrapped around the parent’s waist. Again the parent restrains the hands. Small children may cry during the examination, but the crying will stop as soon as the examination is completed.

Clinical Findings

An oral and dental examination should be systematic. During the examination, take the opportunity to point out abnormalities (e.g., tooth decay) to the parent.

Aberrations in Primary Tooth Eruption

Natal and Neonatal Teeth

The prevalence of natal or neonatal teeth is estimated to be 1:2000 to 3000 births and is equally common in boys and girls. The teeth usually erupt in pairs. Natal and neonatal teeth have been shown to occur in about 50 different syndromes, of which about 10 are associated with chromosomal aberrations. More than 90% of these prematurely erupting teeth are mandibular central incisors belonging to the normal dentition, with normal shape and color. Supernumerary teeth may be abnormal in shape and color and only loosely attached to the gingiva. Natal or neonatal teeth can lead to gingivitis, self-mutilation of the tongue, and trauma to the mother’s breast. However, they should be extracted only if they are loose enough to involve risk of aspiration or if feeding is severely disturbed. Most will develop normally with normal root structure (Leung and Robson, 2006).

Delayed tooth eruption

Delayed tooth eruption can result from either systemic or local factors. These include prematurity, low birthweight, genetic syndromes (e.g., Down and Turner syndromes), a diet low in protein, children born to mothers with severe goiter (iodine deficiency), hereditary gingival fibromatosis, and adjacent supernumeraries or dental tissue tumors (odontomes) (Crawford and Aldred, 2005; Hayes and Thornton, 2007). In general, children with chronic diseases who show delay in both physical and dental development experience delayed but otherwise normal tooth eruption. Parents may need reassurance if there is some delay. Once the child is old enough to tolerate dental x-rays, no earlier than 4 years old and often later, diagnostic films can be taken to provide a better assessment of the developing dentition.

Other Gum Events

Preeruption Cysts

When a tooth starts erupting through the gingival tissue, a blood-filled cyst may precede it. Alarmed parents may report a purple, reddish, black, or blue bump or bruise in their child’s mouth. If the enlargement is on the alveolar ridge, reassurance is all that is required. The symptom will resolve as the tooth erupts (Fig. 33-2).

FIGURE 33-2 Preeruption cyst. Eruption hematomas (arrows) have developed before the eruption of the second primary molars.

(From McDonald RE, Avery DR, Dean JA: Dentistry for the child and adolescent, ed 8, 2004, Mosby, p 182.)

Congenital Epulis

Congenital epulis is a fibrous, pedunculated, soft-tissue enlargement that occurs on the maxillary alveolar ridge at birth (Fig. 33-3). This condition is more common in female babies. It typically regresses with time, but large lesions should be excised.

FIGURE 33-3 Congenital epulis.

(From Gnepp DR: Diagnostic surgical pathology of the head and neck, ed 2, Philadelphia, 2009, Elsevier.)

Bohn nodules are present at birth and appear as firm nonpainful nodules on the buccal surface of the alveolar ridge (Fig. 33-4). They are remnants of dental lamina connecting the developing tooth bud to the epithelium of the oral cavity. No treatment is required because they will resolve spontaneously. If they appear in the midline of the palate, they are referred to as Epstein pearls.

FIGURE 33-4 Bohn’s nodule.

(From Eichenfield LF, Frieden IJ, Esterly NB: Neonatal dermatology, ed 2, Philadelphia, 2008, Mosby.)

Professional Dental Care

Access To Dental Care

Numerous studies report considerable disparities in oral health and access to care, with the greatest burden experienced by low-income, ethnic minority children in households with low child or parental education, and in smokers (Beltrán-Aguilar et al, 2005; Edelstein and Chinn, 2009; Klein, 2009; Tinanoff and Reisine, 2009; USDHHS, 2003). Those without insurance are four times as likely to have unmet dental needs as those with some form of public insurance (Bloom et al, 2009). Although Medicaid-enrolled children have better access to dental care than uninsured children (Bloom et al, 2009), they continue to exhibit low dental utilization rates (less than 60%) (Chi and Milgrom, 2009). This could be due to dentists’ unwillingness to accept Medicaid insurance (because of low reimbursements rates) and high no-show rates (Al Agili et al, 2007; Iben et al, 2000). Low preventive care utilization rates can result in a cycle of emergency care with less comprehensive treatment, pain, and then more symptomatic care.

Fear of the Dentist

Parents’ and caregivers’ own fear of the dentist can have a negative effect on the oral health of children. As many as one in five adults in North America profess such fear (Smith and Heaton, 2003). Many of the parents of children with whom primary care providers interact may have this fear and consequently avoid dental visits themselves.

Early and consistent primary prevention is the best way to avoid the development of fear and avoidance (Weinstein and Milgrom, 2006). Allowing tooth decay to go untreated until a child is school age results in extensive restorative intervention—a traumatic experience for any child. Dental restorative care is the only area of medicine in which children are expected to endure extensive surgery while they are awake. Hospitalizing children and performing reparative services under general anesthesia is a scarce, expensive, and risky option. Moreover, the majority of children experience recurrence of disease within 6 months because the surgical treatment does not address the underlying problem.

Choosing a Dentist

The choice of a dentist is critical, especially for children who have had poor previous experiences. Many general dentists are skilled at working with children, so the absence of a pediatric specialist is not a huge barrier. A dentist new to the child should be told about any prior dental experiences. Parents of dentally naive children should be counseled to choose a dentist known to like and work well with children. Parents should be encouraged to ensure that their child has had a good night’s sleep and is fed before a visit. The child’s teeth should be brushed before any visit to the dentist. A parent or caretaker should accompany the child into the treatment room; avoid dentists who are adverse to such. Counsel parents to avoid dentists who rely only on pharmacology to manage behavior, such as using nitrous oxide, oral antihistamines, or narcotics. The most effective strategies are behavioral. Combinations of behavioral and pharmacologic methods—such as distraction and nitrous oxide—can be effective, whereas the drug alone may not be.

Preparation should focus on helping the child develop coping skills and ways to gain control. Children gain control when the dentist briefly explains procedures and allows them to signal any discomfort. An example of a coping skill is relaxation breathing. Finding a dentist who tells stories and riddles, sings to the children, or otherwise distracts them (e.g., with videos, music, or games) is particularly effective. Directed guidance strategies—specific kinds of direction followed by praise—are also very effective in managing children’s behaviors. For fearful children, practitioners can be successful by using structured rehearsals, in which procedures are broken into small steps, and teaching coping strategies. Dentists and parents who rely solely on authoritarian approaches or who are permissive are likely to fail with a fearful child (Weinstein and Milgrom, 2006).

Parents should be cautious about dentists with laser-based diagnostic devices. These devices are often marketed to dentists as being capable of detecting “invisible” cavities. They are being misused to justify unnecessary fillings, often called “preventive resins.” The standard method of examination of the teeth is visual, using strong light and transillumination (shining light through the tooth) without using sharp probes, which can damage teeth and transfer potential pathogenic bacteria from one groove or surface to another. Most tooth decay in permanent teeth in children occurs on the biting surface, and x-rays are of limited diagnostic value in such cases. Parents should be urged to seek second opinions whenever eight or more fillings (two for each quadrant of the child’s mouth) are recommended.

Dental Health Education

Dental health education is a crucial preventive strategy. Tailoring health education messages and instruction to an individual’s capacity to “obtain, process, and understand” reflects a health literacy approach to oral health education. Low parental health literacy is most often associated with early childhood caries, low income, and inadequate maternal education. Low reading literacy, combined with low health literacy, is of particular concern given the dual role a parent plays as decision-maker for self and child. The potential negative consequences for health and safety escalate.

Health information that is accessible to individuals with limited literacy is just beginning to influence dentistry. A review of dental education materials for parents found many required reading skills above the seventh to ninth grades. Additionally, many materials included dental jargon and unnecessarily difficult words (Alexander, 2000). The same study found that more than 80% of secondary school children (spanning a reading level equivalent to that of adults) were unsure of many dental terms, such as “fluoride tablets” and “gum disease.” The advice given in published materials often is inconsistent. In addition, there are many oral health myths that should be dispelled by the PCP during conversations on oral health (e.g., caries in baby teeth aren’t important since they eventually fall out anyway; it is “impossible” to brush children’s teeth; fluoride is unsafe; pregnant women shouldn’t see the dentist).

A good source of reference material on the Internet is www.medlineplus.gov, the consumer side of PubMed from the National Library of Medicine. Access is free, and materials are often in multiple languages. The site includes brochures that can be freely downloaded and copied.

Reducing Disparities Through Preventive Intervention and management

Weinstein and colleagues (2004) have shown that parents of young children are willing and able to change home preventive oral health practices. Using an intervention based on the transtheoretical “stages of change” model of Prochaska and Norcross, individuals overcome self-identified barriers to change, setting goals that are attainable and of personal value (Weinstein and Milgrom, 2006; Weinstein et al, 2004) (see Chapter 9 for discussion of this model).

Parents’ toothbrushing skills and oral hygiene education can be improved when staff in the primary care clinic, preschool, Head Start, or Women, Infants, and Children (WIC) program demonstrate proper technique and give parents a chance to practice. Researchers found that oral hygiene and gingivitis scores improved in children when instructions about oral health were reinforced both in the home and at school (Kwan et al, 2005). Davies and colleagues (2005) reported positive benefits of a series of “gifts” by mail to parents of infants 8 through 32 months old. The gifts included written educational pamphlets, a trainer cup, toothpaste, and a toothbrush. Parents who received the repeated mailings versus those who did not were more likely to report favorable feeding behaviors, initiation of toothbrushing before 12 months old, and twice daily toothbrushing.

Beil and Rozier’s study (2010) evaluated whether a recommendation by a PCP to see a dentist resulted in more dental checkups in children. They found that children 2 to 5 years who received such a recommendation were more likely to have a dental examination, whereas children from 6 to 11 years of age showed no increase. This supports the efficacy of the recommendation that primary care providers refer children to a “dental home” at an early age.

Bacterial Diseases of the Mouth

Tooth Decay (Cavities, Dental Caries)

Description and Epidemiology

The Centers for Disease Control and Prevention (CDC) notes that of the approximately 50% of children who have had decay, two thirds of these children are in the 12- to 19-year-old range (CDC, 2010a); about one quarter are from 2 to 5 years old. Tooth decay is a bacterial disease that can result in irreversible damage and potential loss of teeth. The decay is caused by lactic acid demineralization of the tooth subsurface enamel. The acid is produced by an alpha hemolytic streptococcus (mutans streptococci), in older literature referred to as Streptococcus mutans, after metabolism of carbohydrates in the diet. Unless neutralized and buffered by saliva (remineralized), the demineralization process will lead to cavitation. Active cavities are also frequently infected with lactobacilli. The bacterial species are part of the biofilm adherent to the teeth. The bacteria are usually transmitted when saliva is shared between the child, caregivers, or other children (California Dental Association Foundation, 2010). Infection and colonization peak around the time of the eruption of the primary teeth, but may occur before.

In infants the carbohydrates may be present in the form of prolonged exposure to formula or breast milk, especially if the infant is allowed to sleep with the nipple in his or her mouth (Azevedo et al, 2005; van Palenstein Helderman et al, 2006). Before and after weaning, carbohydrates may also come from milk sweetened with honey or sugar or from juices in baby bottles or training cups, especially when given at bedtime, naptime, or when a child is allowed to take swigs of the fluid throughout the day. In older children, the source of the carbohydrates may be Tang, Kool-Aid, sports drinks, and/or soda. This frequent carbohydrate exposure keeps the pH of mouth fluid near the tooth surface below 5 and results in an environment conducive to demineralization. The neutralization process does not have enough time to increase the mouth pH to a level that would allow remineralization. In patients undergoing chemotherapy or radiation to the head and neck and in patients who are immunocompromised, normal salivary flow and salivary buffering of acids is disrupted. Cavities result. Box 33-1 provides a list of risk factors associated with dental caries in children.

BOX 33-1 Factors That Increase a Child’s Risk for Developing Dental Caries

Health and Personal History

• Extra health care need associated with poor motor coordination or cooperation

• Xerostomia

• No dental home

• Previous history of tooth decay

• Braces or orthodontic appliances

• Child’s parent or sibling has tooth decay

• Low socioeconomic status

• Frequent exposure to fermentable carbohydrates (e.g., snacking more than three times per day)

• No exposure to topical fluoride

Clinical Evaluation

• Visible plaque on teeth

• Gingivitis (red, swollen gums)

• Demineralized enamel (white spot lesions on teeth)

• Enamel defects (e.g., hypercalcification, deep pits and fissures)

Supplemental Findings

• Radiographic evidence of enamel caries

• High levels of mutans streptococci

Adapted from American Academy of Pediatric Dentistry (AAPD): Reference manual 2009-2010: policy on use of a caries-risk assessment tool (CAT) for infants, children, and adolescents, Pediatr Dent 31(special issue):29-33, 2009a.