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 As 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…

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 shes been taking less formula and wonders if its because shes 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 StudyMethodsOutcome Wake et al (Australia, 2000) Prospective study of 21 infants assessed by staff for teething & temperature No association between teething and fever Macknin et al (USA, 2000) Prospective study of 125 infants assessed by parents for teething & temperature Fever <38.5 was associated with teething period of +/- 1 day compared to non-teething days Jaber et al (Israel, 1991) Prospective study of 46 infants. Temperature assessed by parents. Tooth eruption assessed by staff. Temperature increase to 37.9 associated with the day of tooth eruption compared to preceeding days Peretz et al (Colombia, 2003) Retrospective questionnaire completed by parents of 585 teething children 60% of teething children had fever > 39, but no comparison to fever in control children

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 1 st are less protected by saliva

24. Dental caries - Pathogenesis

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

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

27. Prevention – oral hygiene AgeToothbrushing Recommendations (CDC 2001) < 1-2 yearsParent cleans with cloth or soft toothbrush. No toothpaste 2-6 yearsPea-sized amount of fluoride-containing toothpaste twice per day Floss Qday Parent supervises > 6 yearsBrush independently twice per day

28. Preventive – Dental Home Beginning at 6-mo pediatricians should: Assess mothers oral health. Assess oral health risks* Examine mouth/teeth and recognize signs/symptoms of caries. Assess childs 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 (1) combining into & strengthening enamel (2) 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 http://apps.nccd.cdc.gov/MWF/Index.asp Supplement if low fluoride levels in water supply, or child doesnt drink water

31. Fluoride supplementation

32. Case #8 Youre 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 Dont 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:

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

38. 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?

39. 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

40. 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 Orthod Dentofacial Orthop. 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 http://apps.nccd.cdc.gov/MWF/Index.asp

41. The End – SMILE!