Pediatric Dental Health

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Is Your Toothbrush Contaminated?
Have you ever wondered what happens to the nasty "bugs" that you brush off of your teeth? The truth may surprise you. Many of the bacteria, fungi, and viruses actually remain on your toothbrush! So the next time you use a contaminated toothbrush, remember that the infectious microorganisms remaining on the brush can reinfect your mouth and teeth again! Some of the microorganisms can even spread to the rest of your body.

SOME OF THE MICROORGANISMS REMAINING ON TOOTHBRUSHES:

1. Mutans streptococcus - the main bacterium causing dental caries.
2. Beta-hemolytic streptococcus - the main bacterium causing strep throat (pharyngotonsillitis).
3. Candida albicans - the main fungus causing thrush in babies.
4. Coliform bacteria - these are found in the bathroom.
5. Herpes simplex virus - they causes cold sores.

WHO IS AT RISK?
Children or adults with an oral infection, such as dental caries.
Family members related to a child or adult with an oral infection.
Immunologically compromised children or adults.
Children or adults who are undergoing chemotherapy, bone marrow transplant, or organ transplant procedures.

HOW TO PREVENT TOOTHBRUSH CONTAMINATION:
1. The American Dental Association recommends changing toothbrushes every three months.
2. Sick children or adults should replace their toothbrushes as soon as possible - to prevent reinfection, or infection of another person.
3. Children or adults who are immunocompromised, or undergoing chemotherapy should change their toothbrushes every three days.
4. Always store toothbrushes in an aerated and ventilated environment - never sealed-up in a closed container.
5. Label and clearly identify each child's toothbrush, so that sharing of toothbrushes is avoided. Do not let children share toothbrushes!
6. Disinfect all toothbrushes daily.

METHODS OF DISINFECTING TOOTHBRUSHES:
1. Disinfect contaminated toothbrushes overnight in a solution of household bleach (sodium hypochlorite). Then rinse in clean water, and allow to air dry. Keep the bleach in a plastic container - not a metal container.
2. Keep all bleach products well out of reach of children! In case of accidental ingestion of bleach, do not induce vomiting, but give plenty of water.
3. You can also disinfect toothbrushes by cleaning them in a dishwasher every night - along with eating utensils. Allow them to air dry afterwards.

A recent article published in Pediatric Dentistry discussed toothbrush contamination in a day care setting. The article concluded that toothbrushes can be adequately disinfected by soaking them either in a 0.12% chlorhexidine gluconate solution (Peridex) for 20 hours, or in a 1 % sodium hypochlorite solution (1 part bleach, 4 parts water) for 20 hours.

Filho PN, Macari S, Faria G, Assed S, Ito IY: Microbial contamination of toothbrushes and their decontamination. Pediatric Dentistry. 2000 22(5) 381-384.

Can We Prevent Dental Caries In Children?
In spite of the current emphasis on preventive dental health, many children are still affected by dental caries. In fact,dental caries is the most common chronic infectious disease of childhood. By the age of 6, more than 40% of U.S. children are affected by this disease. Early childhood caries remains a severe problem in some cultural and ethnic groups. All told, more than $40 billion is spent each year on prevention and treatment of dental caries in the U.S.

WHAT IS DENTAL CARIES?
1. Dental caries is a lifestyle-dependent infectious disease.
2. The lactic acid produced by the cariogenic bacteria causes tooth structure to dissolve. It destroys dental enamel - the hardest material in the body. When dental decay spreads to the nerve and pulp tissues of the tooth, the result can be dental pain, dental abscess, or facial cellulitis.

WHAT CAUSES DENTAL CARIES?
1. The oral bacteria responsible for dental caries belong to the streptococcus mutans and lactobacilli groups of bacteria.
2. These bacteria, which cause dental caries, are able to metabolize sugar, produce a destructive lactic acid, and produce a sticky dental plaque. This destructive acid dissolves the mineral structure (hydroxyapatite crystals) of teeth. If the tooth mineral continues to be lost because of acid attack, the surface of the enamel will eventually be cavitated, producing a cavity.
3. The bacteria which cause caries are usually "passed on" from mother to infant, as early a 10 months of age. The danger of infecting an infant's teeth is increased if the mother already has the caries disease herself.
4. Children who frequently consume refined sugar products, such as candy and soft drinks, have a high risk of developing dental caries. Sucrose, a type of sugar, is therefore an important contributor to dental caries
5. The newly erupted teeth of infants are the most susceptible to caries because they are not yet fully hardened (calcified). Calcium and phosphate in the saliva help fight dental caries by gradually "maturing" the tooth enamel.

HOW CAN PARENTS IDENTIFY DENTAL CARIES?
1. The first sign of dental caries is a white spot "lesion" on the enamel surface of the front teeth. These are white, chalky areas, close to the gum line. These decalcifications are caused by bacterial acid, and directly precede irreversible loss of tooth structure (a cavity).
2. By "lifting-the-lip" parents will be able to see this early indicator of caries disease.
3. Parents should get these areas examined by a dentist as soon as possible, so that treatment can be initiated, if necessary. The white spot lesions can be "reversed" (remineralized) by the application of fluoride - if the problem is recognized early enough.
4. Active cavities usually have a golden-brown color.

HOW DOES FLUORIDE PREVENT CARIES?
1. Fluoride contacting the teeth forms a layer of calcium fluoride-like material on the surface of the tooth enamel. When acid from oral bacteria accumulates on the teeth, fluoride is released from this protective layer. This released fluoride then aids in hardening (remineralizing) the enamel.
2. Fluoride inhibits the ability of bacteria to metabolize sugar, because it interferes with the way bacterial enzymes work.
3. Fluoride inhibits demineralization of enamel, because it inhibits the breakdown of carbonated hydroxyapatite by bacterial acid.

HOW CAN PARENTS PREVENT DENTAL CARIES?
1. Parents can modify oral hygiene techniques, depending on the child's age. For small infants, the gums need to be cleaned once or twice a day with a piece of clean gauze. This will help to establish a healthy oral environment for the baby teeth. Infants should be introduced to the toothbrush around the age of one.
2. Parents should not put children to sleep with a bottle containing any liquid other than water. Parents should encourage their infants to begin drinking from a cup around their first birthday.
3. Parents should help brush their children's teeth every day, after every meal.
4. Parents should not let their children drink fruit juice or sweetened drinks from a bottle or "tippy" cup, since this prolongs the exposure of teeth to harmful sugar.
5. Parents should provide healthy, balanced meals for children. They should limit the amount of sugar-laden foods and snacks in their diet. Plenty of healthy snacks should be available for children. Cheese products actually fight dental caries.
6. Parents can help make children's teeth more decay-resistant by using an ADA-approved children's toothpaste. Place only a pea-sized drop of toothpaste on the toothbrush. Until a child is 3 years old, parents should only use baby tooth cleanser - to avoid causing fluorosis discoloration of the adult teeth.
7. Children taking oral medications should have their teeth cleansed after each dose of medication. Nearly 100% of children's medications contain sucrose, which can increase the risk of developing dental caries.
8. Children should have their first oral/dental health evaluation by the age of 12 months, or within 6 months of the eruption of the first tooth.
9. Parents should consider providing children with xylitol-containing chewing gum, which can help prevent dental caries.

FUTURE TRENDS IN CARIES PREVENTION:
1. Chemotheraputic methods of fighting the caries-causing bacteria will be used. These methods include the application of fluoride varnish and chlorhexidine gel on teeth.
2. Vaccines against dental caries. The vaccines would function by giving a child an improved IgA or IgG immune response to cariogenic bacteria.
3. Molecular probes to measure the level of cariogenic bacteria in a child's mouth.
4. Earlier caries detection, including fluorescence and ultrasonography.
5. Laser treatment of teeth. This technique would inhibit the progression of dental caries by making the enamel surface highly resistant to acid attack.

The good news is that we can prevent dental caries in children! By providing a healthy diet, minimizing the consumption of sweets, cleaning children's teeth at least twice a day, and getting early dental examinations, children can enjoy a happy, healthy smile.

A recent article in Pediatric Clinics of North America discussed dental caries. It described methods of recognizing cares, the epidemiology of dental caries, it pathogenesis, and its clinical management.

Caufield CW, Griffen AL: Dental caries: An infectious and transmissible disease. Pediatric Clinics of North America. October 2000. 47(5);1001-10019.

Dental Infections In Children
Dental infections are a distressing experience for a child and the parents. Dental infections in children are usually related to untreated dental caries. The first indication of an infection is usually oral or dental pain - often spontaneous. The offending tooth will often hurt during the night. Any child with a dental infection needs to be promptly evaluated and treated by a dentist. Prompt treatment will prevent the development of serious health complications.

WHAT KINDS OF DENTAL INFECTIONS ARE THERE?
1. Acute infection (facial cellulitis). This is a serious and painful problem. The child may have a swollen face, an elevated temperature, appear sick, and be dehydrated. This sort of infection can spread to other parts of body such as the deeper structures of the head and neck.
2. Chronic infection (dental abscess). This problem usually takes longer to develop. An abscess is really a walled-off infection, and is usually less serious than a facial cellulitis. A dental abscess feels soft to the touch, because it is pus-filled. Often, a small localized, swelling is seen on the gums next to the offending tooth. The offending tooth may be loose or painful to the touch.

WHAT CAUSES A DENTAL INFECTION?
1. Deep dental caries can infect the dental pulp (the center of a tooth), and cause a tooth to die (pulp necrosis).
2. When an infection of the dental pulp invades the supporting bone, or adjacent areas of the face and neck - it results in a true dental infection. This first step is the inoculation stage of a dental infection.
3. A dental infection is usually caused by a number of bacteria acting at the same time. Some of these infectious bacteria need oxygen to survive (aerobic bacteria), and some can't tolerate oxygen (anaerobic bacteria).
4. The first bacteria "on the scene" in a dental infection are usually the aggressive aerobic bacteria. They cause the development of a cellulitis, which is a hard, red, tender, warm, and rapidly swelling enlargement.
5. From the fourth to the seventh day of an infection, the anaerobic bacteria - which cause a deeper infection- become more numerous. This causes a central, softened area to develop - which is called a necrotic abscess. This abscess contains pus - which consists of dead tissue, live and dead bacteria, and white blood cells.

HOW DOES A DENTAL INFECTION SPREAD?
1. Teeth can carry the infection-producing bacteria deep into the supporting jaw bone - via the outer root surfaces and inner canals of the dental roots.
2. Once bacteria have spread to the outer surface of the tooth's roots (periapical/interradicular area), the infection will spread along the path of least resistance.
3. The most common dental infection in children is the dental abscess, which is less serious than facial cellulitis. The dental abscess is often localized in the area of the mouth where the cheek meets the gums (the oral vestibule).

HOW DOES A DENTIST DIAGNOSE A DENTAL INFECTION?
1. First, the dentist obtains a complete history of the illness, including the child's symptoms. The symptoms of a dental infections may include: a toothache, a bad taste in the mouth, bad breath, fever, malaise, and general discomfort.
2. Next, a physical examination is performed. This can include obtaining the child's vital signs, examining and palpating the swollen area, performing an intraoral examination, taking x-rays (radiographs), and developing a preliminary diagnosis.
3. The dentist will usually take an x-ray of the roots of the tooth (periapical view), and may also take a dental panoramic radiograph to view all of the child's upper and lower teeth and jaws (maxilla and mandible).

WHAT ARE THE COMPLICATIONS OF DENTAL INFECTION?
1. The affected child may be dehydrated, and be in pain.
2. The child's body temperature may exceed 101 degrees F, which indicates a severe infection.
3. Trismus may develop. This is the inability to open the mouth widely. It is caused by inflammation of the chewing muscles (muscles of mastication).
4. A dental infection can spread deep into the face and neck, and may require surgical drainage in order to resolve the problem.
5. Deep (fascial space) infections of the face, head, and neck can quickly produce life-threatening complications.

HOW IS A DENTAL INFECTION TREATED?
1. The most important step in treating a dental infection is removing the source and cause of the infection. This often means: removing (extracting) the offending tooth. Extracting the offending tooth has the additional benefit of providing a way to drain accumulated pus.
2. Any accumulated pus needs to be drained from the infected area. Sometimes, this means that advanced (surgical) drainage procedures will be needed.
3. Antibiotics are of secondary importance in treating a dental infection,and antibiotics are not automatically used to treat dental infections. Antibiotics are used for treating infections involving: rapidly progressive swelling, diffuse swelling, a medically compromised child, or an infection that has invaded the extraoral (fascial) spaces.
4. If a child with an infection is dehydrated, IV fluids may need to be administered.
5. If a child's temperature exceeds 101 degrees F, hospitalization might be required. Most dental infections in children can be prevented by obtaining regular dental checkups, and by prompt treatment of any dental caries.

A recent article in Emergency Medicine Clinics of North America reviewed the topic of dental infections. It described clincial examination, airway evaluation, radiographic evaluation, culture and sensitivity testing, intraoral examination, clinical appearance of deep orofacial infections, treatment of odontogenic infections, and complications of odontogenic infections.

Flynn TR: Oral-facial emergencies. The Swollen face. Emergency Clinics of North America. 18(3) August 2000.