Pediatric Dental Health

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Does Day Care Spread Disease?
Children attending day care are very good at sharing a number of bacterial, viral, and parasitic infections with each other. Day care is an ideal environment for the spread of disease among children, because: the children move about and interact with other, their personal hygiene is less than ideal, their ability to control their bodily secretions and excretions is poor, and their immune systems are not yet fully developed.

TYPES OF CHILD CARE SERVICE:

Small-family child care, which is provided in a private residence for less than 6 unrelated children.
Large-family child care, which is provided in a private residence for 7 to 12 children.
Center child care, which is provided in a non-residential setting for 13 or more children.
Sick-child care, which is provided for mildly ill children.

WHY ARE CHILDREN ATTENDING DAY CARE SUSCEPTIBLE TO INFECTIONS?
They explore the environment with their mouths, usually drooling in the process.
They have poor control of their secretions (saliva) and excretions (feces).
They have frequent close contact with other infants and toddlers.
They all have direct contact with the same day care providers.
They have immature immune defense systems.
Their personal hygiene is less than ideal.

HOW IS DISEASE SPREAD IN DAY CARE FACILITIES?:
The Fecal-Oral Route: It is responsible for Escherichia coli O157:H7 and hepatitis A infections. Note that the risk for food contamination is higher when the person who prepares or serves the food also diapers the children.
The Respiratory Route: It is responsible for Bordetella pertussis, Haemophilus influenza, Mycobacterium tuberculosis, Streptococcus pneumonia, measles, mumps, and varicella zoster virus infections.
By Skin Contact: It is responsible for head lice and scabies infections.
The Blood, Urine, or Saliva Routes: They are responsible for cytomegalovirus, hepatitis B and C virus, and herpes simplex virus infections.

HOW TO PREVENT THE SPREAD OF ORAL HERPES (HSV-1) AND HEPATITIS B (HBV) IN DAY CARE FACILITIES:
Day care providers must practice excellent personal hygiene with frequent handwashing, using soap and water.
All shared toys must be cleansed in the dishwasher, or disinfected with a 1:64 solution of household bleach, at least once a day.
Children should not share food, drinks, eating utensils, cups, or drinking glasses.
Children should not share toothbrushes.

PREVENTING THE SPREAD OF DISEASE IN DAY CARE:
Caregivers must wash their hands frequently with soap and water, especially after diapering children.
Written procedures for diaper changing and handwashing should be posted and enforced.
Caregivers must practice hygienic methods of diapering infants and toddlers.
Caregivers must practice meticulous personal hygiene.
Caregivers must have their immunizations updated and recorded.
All children must have their immunizations updated and recorded.
Communicable diseases in the day care center need to be reported to the health department.
Written policies should be in place for managing child and employee illness.
Infants and toddlers should be separated to reduce infections.
Sanitation procedures must be thorough.
Food handling procedures must be strict.
Food should be handled hygienically and safely to prevent the spread of disease. Hands should always be washed before handling food. Staff members who change children's diapers should not prepare or serve food.
Practice hygienic procedures for child toilet use.
Toilet areas and toilet training equipment must be maintained in a sanitary condition.
Each item of sleep equipment should only be used by a single child.

The AAP 2000 Red Book includes a chapter on day care infections.

Children in Out-Of-Home Child Care: AAP 2000 Red Book: Report of the Committee on Infectious Diseases. 25th ed; American Academy of Pediatrics; 2000:pp105-119.

Emergency: A Child's Tooth Has Been Knocked Out!
One of the most distressing experiences for a child is to have a permanent front tooth knocked out. This may happen as a result of a sports mishap, a fall inside of the home, or other trauma. Every tooth has a protective layer surrounding the root, which is called the periodontal ligament. The periodontal ligament is very sensitive, and will quickly dry out and die - unless the tooth is immediately placed in a protective solution, such as milk or saline. With every minute that the tooth is left out of the mouth to dry, more cells in the periodontal ligament will die.

The best way to preserve a tooth which has been knocked out (avulsed) is to put it back into its socket as quickly as possible. If that isn't possible, the tooth should be placed into a protective solution. The goal of reimplanting the tooth into the socket is to preserve the health of the tooth's outer periodontal ligament. If the cells of the periodontal ligament are allowed to die, the child will eventually loose the tooth.

FIRST AID FOR AN AVULSED (KNOCKED OUT) TOOTH:
1. Do not touch the root of the tooth. Handle the tooth by the crown only.
2. Rinse the tooth off only if there is dirt covering it.
3. Attempt to reimplant the tooth into the socket with gentle pressure, and hold it in position.
4. If unable to reimplant the tooth, place it in a protective transport solution, such as Hank's solution, milk, or saline. This will hydrate and nourish the periodontal ligament cells which are still attached to the root. A small container of Hank's Balanced Salt Solution can be purchased in dental emergency kit form at many drug stores.
5. The tooth should not be wrapped in tissue or cloth.
6. Take the child to a dentist or hospital emergency room for evaluation and treatment.

PROCEDURES IN THE DENTAL OFFICE OR HOSPITAL EMERGENCY ROOM:
1. Place the tooth in Hank's Balanced Salt Solution.
2. Take a medical and dental history, and perform a physical examination. Rule out CNS injury.
3. Examine the orofacial area. Inspect the oral soft tissue for embedded tooth fragments, lacerations, or ecchymosis. Palpate the teeth and dentoalveolar area to check for mobility. Evaluate TMJ function.
4. If the tooth is missing, rule out aspiration or ingestion.
5. Take a maxillary occlusal radiograph, as well as a lateral anterior radiograph of the injured area. Consider taking a panoramic radiograph to rule out condylar or mandibular fractures.
6. Gently aspirate the injured area without entering the socket. If a clot is present, dislodge and remove it using light saline irrigation. Do not curette the socket.

TOOTH REIMPLANTATION GUIDELINES:
1. For A Mature Tooth With A Closed Apex: If the extraoral dry time is <60 minutes, reimplant as soon as possible. If the extraoral dry time is >60 minutes, soak in citric acid or curette the root; then soak in fluoride for 10 minutes. Rinse with saline.
2. For An Immature Tooth With An Open Apex: If the extraoral dry time is <60 minutes, soak in doxycycline (1mg/20 ml saline) for 5 minutes. If the extraoral dry time is >60 minutes, provide the same treatment as for a closed apex.
3. Apply a functional splint for 7 to 10 days. If an alveolar fracture is present, provide a rigid splint for 4-6 weeks.
4. After reimplantation, gently compress the facial and lingual bony plates. Suture any lacerations.
5. Provide antibiotic coverage for 7 to 10 days to prevent infection. Consider prescribing tetracycline or amoxicillin.
6. Prescribe chlorhexidine gluconate rinses, and provide oral hygiene/diet instructions.
7. Provide analgesics to control pain. For children, consider prescribing acetaminophen and codeine (Tylenol #3) for mild to moderate pain. The dose is 15 mg/kg/dose of acetaminophen, every 4 hours. Do not exceed 2.6 G/day of acetaminophen.
8. Arrange for tetanus vaccination if the wound was dirty, or if the vaccination requires updating.

FOLLOW-UP CARE AFTER 7 TO 10 DAYS:
1. For a tooth with an open apex and extraoral dry time <60 minutes: no endodontic treatment is initially required. Re-evaluate every 3-4 weeks for pathosis. In case of pulp pathosis, begin an apexification procedure.>
2. For a tooth with an open apex and extraoral dry time >60 minutes: begin an apexification procedure.
3. For a tooth with a closed apex: provide traditional endodontic treatment and obturation.
4. Remove the splint at this 7 to 10 day treatment visit.

ENDODONTIC OBTURATION FOR AVULSED TEETH WITH CLOSED APICES:
1. For a tooth with endodontic treatment started 7 to 10 days after avulsion, obturate after 1 to 2 months of treatment with calcium hydroxide paste.
2. For a tooth with radiographic signs of resorption or pathosis, or for a tooth which had endodontic treatment started more than 14 days after the avulsion, treat long term with a dense mix of calcium hydroxide. Obturate when an intact lamina dura can be visualized.

A recent article in the British Dental Journal examined the effect of various factors on the prevalence of external root resorption in avulsed teeth. This study concluded that the major risk factors for external root resorption were the degree of root contamination, and the extraoral dry time.

Kinirons MJ, Gregg TA, Welbury RR, Cole BOI: Variations in the presenting and treatment features in reimplanted permanent incisors in children, and their effect on the prevalence of root resorption. British Dental Journal. Sept 9, 2000. 189(5)263-266.

What Are Dental Eruption Cysts?
A dental eruption cyst is an oral soft tissue cyst which appears during childhood, and forms around an erupting primary or permanent tooth. Eruption cysts are not malignant.

Forty-five percent of all children experience eruption cysts. Eruption cysts and eruption hematomas are very similar, and differ only in their color. Both types of cysts are smooth, soft, swellings which appear over the area where a child's tooth is about to come in. They may be as large as 1/4 inch in diameter. They usually are clear, or may have a bluish color. Eruption hematomas are simply eruption cysts which have a very dark color.

WHEN DO ERUPTION CYSTS APPEAR?
1. Shortly before the underlying tooth erupts into the mouth.
2. They can appear as early as 5 months of age, or as late as 12 years of age.

WHAT CAUSES AN ERUPTION CYST?
1. An eruption cyst develops when fluid accumulates between an erupting tooth and the overlying layer of enamel epithelium.
2. An eruption cyst is really a dentigerous cyst which appears in oral soft tissue.

WHAT IS THE TREATMENT FOR AN ERUPTION CYST?
1. Most eruption cysts disappear spontaneously as soon as the underlying tooth erupts into the mouth.
2. No treatment is usually needed, since most of these cysts heal within 5 weeks.
3. Giving an infant a cold teething ring may help alleviate some of the discomfort associated with eruption cysts.
4. When a child experiences feeding problems or severe discomfort as a result of eruption cysts, it may be necessary to have them incised or surgically removed.

A recent article which appears in the Journal of Dentistry for Children reports a case of a fifteen-month-old boy who experienced multiple dental eruption cysts. The cysts were causing some feeding problems, as well as discomfort. The problem was treated surgically by incising the eruption cysts, and removing part of the overlying cystic tissue.

Boj JR, Garcia-Godoy F: Multiple eruption cysts:report of a case. J Dent Child. July 2000 67(4)282-284.

Does Gum Disease Cause Premature Babies?
Birth weight is the most important predictor of an infant's chances of growing and developing normally. There are approximately 250,000 premature low-weight infants born each year in the United States. Approximately one in 10 births result in a preterm low birth weight baby.

Preterm and low birth weight babies are born before 37 weeks, and weigh less than 2,500 grams at birth. The normal, full term, duration of a pregnancy is 40 weeks.

Preterm infants with low birth weight are a major public health concern. Most cases of long-term childhood disability begin as low birth weight infants. The hospital costs associated with premature babies are greater than $5 billion annually in the U.S. The social and emotional costs associated with premature infants are also staggering.

Researchers estimate that 18 percent of these premature births may be related to infectious oral disease in pregnant women. Periodontal (gum) disease may cause a sevenfold increase in the risk of delivering a premature low birth weight baby. If periodontal disease in pregnant women were eliminated, the number of low-weight babies could be reduced by approximately 45,000 in the U.S.

Maternal infection has been linked to preterm birth. Actually, any infection during pregnancy can cause a disturbance in the levels of maternal hormones and cytokines. Oral infections, such as periodontitis, can also cause an increase in the circulating levels of molecules such as PGE2 and TNF alpha (a type of cytokine) .

Labor begins when there is a sudden change in the mother's internal regulatory system. A periodontal infection will accelerate the production of these chemical mediators, and can trigger a premature delivery. In fact, the hormone PGE2 (prostaglandin E2) can be used to induce labor.

Pregnant women should therefore observe meticulous oral hygiene, and should keep their normal dental checkup schedule. Maintaining good oral health during pregnancy will help produce a healthy, happy baby.

A recent article in Periodontology 2000 reviewed the various risk factors for preterm low birth weight. The article also described the mechanisms by which periodontal disease in pregnant women may cause preterm delivery.

Williams CE, Davenport ES, Sterne JA, Sivapathasundaram V, Fearne JM, Curtis MA: Mechanisms of risk in preterm low-birth weight infants. Periodontology 2000. 2000 23:142-150.

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