Case

The mother of an 11 month old boy is concerned that her infant has no teeth while all her friends children have a mouthful. How would you further evaluate this child?

Although most infants begin tooth eruption by 6 months of age, there is tremendous variation. In general, if the infant is growing, gaining, and has normal other ectodermal structures like hair, skin, and nails, and there are no dysmorphic features, no evaluation is necessary other than reassurance. Normal number of primary teeth is 20 and there are 32 permanent teeth. Mandibular central incisors are often the first to erupt followed by the maxillary central and lateral incisors. There may be familial cases of absence of individual teeth and certain conditions may be involved with delayed or absent tooth development. Some are:

1. Down Syndrome
2. Ectodermal dysplasia
3. Hypothyroid or hypopituitary

1. Natal teeth- usually are early erupting primary teeth rather than supernumerary. If removed, spacing may be disrupted and lead to orthodontia problems later. If the tooth is loose or is irritating mucous membranes or tongue, and interfering with nursing, tooth should be removed. Common with cleft palate and lip anomalies.
2. Epstein's pearls- on the hard palate and are yellow-whitish deposits of epithelial cells
3. Bohn nodules - similar yellow-whitish cysts on the alveolar ridge.
4. Short lingual frenulum (tongue tie) usually doesn't interfere with feeding or speech and should be left alone.
5. Bifid uvula is often normal but may be associated with submucosal cleft

Although teething may be associated with some discomfort and increased drooling, there is no scientific evidence that it causes systemic symptoms like fever, diarrhea, or rashes. Treatment is symptomatic with acetaminophen and biting on rubber teething ring or cold teething ring. Eruption cysts are bluish blood filled lesions that are on the gums and may precede the eruption of a tooth. May be painful and resolves after the eruption of the tooth.

Fluoride

With the addition of fluoride to public water supplies, the incidence of dental caries has declined sharply. If there is greater than 0.7 ppm of fluoride in the water, there is no reason to supplement. If there is less than 0.3 ppm the child should get 0.25 mg until two years of age followed by 0.5 mg. until adolescence. Most infant bottled water contains fluoride and it is important that infants getting concentrated or powdered formulas are mixing the milk with fluoridated water. Although not clear cut, most experts believe that breast fed infants do not need supplemental fluoride. Excessive fluoride intake may lead to fluorosis, which is staining of the enamel. This is not reversible. Many dental products including rinses and toothpaste contain fluoride and it is important to tell parents to limit the exposure of their children to these products. 

Nursing Caries

Associated with bottle and breastfeeding. Secondary to prolonged exposure to sugar that are acted upon by bacteria. Occurs when infants fall asleep with bottle or breast in mouth. During this time there is decreased saliva production and tongue action. May also be associated with frequency of sugar exposure. Often not painful. Starts initially on the lingual surface of upper teeth and may go unnoticed until the enamel is destroyed. Important to discourage frequent use of bottle and going to bed with a bottle. If treatment not instituted, decay may affect the permanent teeth. Important to initiate discussions with parents about this problem. Significant number of caries may interfere with nutrition.

Color Changes of Teeth

1. Staining secondary to medicines like iron- reversible
2. Fluorosis
3. Trauma can cause grayish tooth
4. Tetracycline exposure.
5. Greenish-black discoloration at gingival margin secondary to tartar and calculus
6. Enamel and dentin abnormalities may cause brown discoloration

This is a controversial area with much bias by individual pediatricians and dentists. In general, if the child stops prior to the eruption of the primary teeth there will be few problems. The child's need to suck must be recognized and parents must be reassured that most children do not go to school with a pacifier. A pediatric dentist once told me that the orthodontia bills are cheaper than the psychiatric bills. Any appliance used to curtail a child's thumbsucking seems cruel.

Trauma

1. Try to save all permanent teeth that are avulsed. Must see dentist immediately. Should either transport in socket or cold milk.
2. Most primary avulsed teeth aren't saved
3. Encourage use of mouthguards in sports.

1. First visit recommended between one and three years of age
2. Early cleaning with cloth or gauze even before teeth erupt after each feeding
3. Most young children need to have their teeth brushed by parents until 10 years of age.  Use a toothpaste that contains fluoride. 
4. Diet recommendations especially the frequency of sugars, nursing, and bottles.  Only water in bottles taken to bed. 
5. Sealants to prevent caries of pits and fissure areas.
6. Floss between teeth once there are contacts between the teeth.
7. Avoid sharing utensils with infants to avoid saliva contact and colonizing their mouths with bacteria that can lead to caries. 

1. Creighton PR. Common Pediatric Dental Problems. Pediatric Clinics of North America. 1998; 45(6):1579-1600.
2. Shusterman, S DMD. Pediatric Dental Update. Pediatrics in Review. August 1994.
3. Nelson's Textbook of Pediatrics
4. Martof, Andrew  Dental Care  Pediatrics in Review Jnauary 2001
5. Wake, Melissa Hesketh, Kylie, Lucas, James.  Teething and Tooth Eruption in Infants: A Cohort Study Pediatrics Vol. 106 No. 6 pg 1374 December 2000
6. Nowak, Arthur J and Slayton Rebecca. Trauma to primary teeth: Setting a steady course for the office.  Contemporary Pediatrics November 2002
7. American Academy of Pediatrics. Oral Health Risk and the Dental Home.  Pediatrics May 2003