Pediatric dental disease is the most common chronic illness of school-aged children.¹ It is five times more common than asthma and has lifelong health implications. Severe tooth decay can lead to bacterial infections within the tissues of the mouth, the bones surrounding the oral cavity, and the sinuses. Pediatric dental disease can lead to malnourishment and pain, and adult dental disease is associated with bacterial pneumonia, diabetes, heart disease, stroke, and poor pregnancy outcomes, including premature labor.¹ It is important to include a close examination of the oral cavity on admission, as many children have not seen a dentist in the past and have undiagnosed pathology. In a study of 120 children on a pediatric ward, more than 40% had unmet oral health needs, as determined by a dental assessment.² Dental caries lead to more cumulative missed school hours than any other chronic disease and can lead to difficulties with eating, drinking, speaking, and paying attention.¹

Children with special healthcare needs are at particularly high risk of severe tooth decay due to their underlying medical issues and barriers to accessing dental care. Dental care remains the most frequently cited unmet health need for this population of children.³ Pediatric hospital medicine physicians can help fill this gap by addressing oral health concerns on admission and facilitating proper dental care after discharge from the hospital.

Intraoral disease may be a primary indication for admission to the hospital (e.g. dental abscess) or may be a secondary finding on an inpatient examination (e.g. aphthous ulcers in lupus [Table 32-1] or delayed tooth eruption due to a genetic disorder [Table 32-2]). Oral lesions, commonly caused by viruses (see Table 32-3) or candida may also lead to such significant difficulty with drinking and swallowing that infants and children may require admission for pain control and treatment of dehydration. See Chapter 70 for a review of causes of stomatitis.

Traumatic mucosal injuries are the most common type of oral injury in infants and young children and may be caused by burns, either chemical (e.g. alkali) or thermal (e.g. hot drinks); by sucking on a pacifier or finger; by sharp objects inserted into the mouth, resulting in abrasions or lacerations; or by blunt trauma.⁴ Many children presenting with mucosal trauma also have injuries involving the teeth.

PATHOPHYSIOLOGY

Dental abscesses generally result from untreated tooth decay, which leads to a deep cavity within a tooth, penetrating through the enamel and dentin into the central pulp. Abscesses can also develop after trauma causes a deep crack in a tooth. Once the pulp is exposed, bacteria can invade, causing the pulp to necrose and resulting in pockets of pus at the base of the tooth (see Figure 32-1 for tooth anatomy).

Children with dental abscesses may present with excruciating pain and swelling within the mouth. Other symptoms may include fever, pain with chewing, sensitivity of the tooth to hot or cold, bad breath, a bitter taste in the mouth, general discomfort, or feeling unwell. The child may also have nausea, vomiting, diarrhea, chills, or sweats. If the abscess has spread, a child may present with complaints of facial swelling, trismus, symptoms of maxillary sinusitis, or difficulty swallowing or speaking.⁵ Of note, a child with a dental abscess may also be asymptomatic, with the infection only noted on thorough examination, particularly if an abscess is draining spontaneously through a sinus tract.

Past medical history may reveal a history of dental caries or trauma to the teeth. Children with a history of osteogenesis imperfecta and other conditions resulting in abnormal dentin are at higher risk of developing dental abscesses from dental caries. Spontaneous dental abscesses are also frequently noted in familial hypophosphatemia or vitamin D–resistant rickets, due to hypomineralization of the dentin and enlargement of the pulp. Children with diabetes and boys are also at higher risk.⁶

Soft tissue injuries within the mouth are generally quite painful and are noted shortly after the trauma occurs. Cuts of the lower lip or tongue are usually caused by biting down during a fall. A child who falls with an object in his mouth such as a pencil or toothbrush may have serious injuries to the posterior oral cavity or pharynx.

On physical examination, the child with a dental abscess may have fever or tachycardia, and depending on the extent of illness, the child may appear sick or uncomfortable. On focused examination of the oral cavity, the gums surrounding an infected tooth are often reddened and swollen, and one may be able to express pus from the base of the tooth. Pain is often elicited on palpation of the tooth, and the tooth may feel loose. Swelling may extend along the base of several teeth. If the infection tracks into the soft tissues of the neck, it can lead to airway compromise, and drooling or a muffled voice may be noted. The abscess also may cause trismus due to pain and swelling.⁵ If the abscess has spread to involve the soft tissues of the face, the child may have notable unilateral swelling of either the jaw or the upper face, depending on whether the lower teeth or upper teeth are involved. The facial skin may be erythematous and warm, particularly when compared to the opposite side of the face. The maxillary sinus can become involved with a dental abscess of the upper teeth, and unilateral maxillary sinus tenderness may be noted on percussion. There may also be unilateral cervical lymphadenopathy, and this may be the only external sign in early dental infections.