Pediatric Dental Health

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Hepatitis C Virus Infection In Children see photo
Hepatitis C virus is the most common, chronic, blood-borne infection in the United States. An estimated 2.7 million people in the U.S. are infected with hepatitis C virus (HCV), and most of them don't even know they are infected. Most people who get hepatitis C have the virus for the rest of their lives.

Hepatitis C can be very serious for some people, but less serious for others. Fifty to eighty percent of people infected with hepatitis C virus (HCV) will develop chronic hepatitis. Chronic HCV infection is responsible for 10,000 deaths every year in the United States, and is the most common reason for liver transplantation in this country.

Hepatitis C is a liver disease caused by the hepatitis C virus (HCV). Hepatitis C is a single-stranded RNA virus in the Flavovirus family. When the liver is infected with this virus, it becomes inflamed, tender, and swollen. Hepatitis C is the only one of the 6 different forms (genotypes) of viral hepatitis that causes the liver to be inflamed. Chronic HCV infection may destroy patches of liver tissue - a process called cirrhosis.

HCV can also infect children. About 5 out of every 100 infants who are born to HCV infected mothers become infected. HCV is transmitted by exposure to infected blood, fluids from serum, and body fluids that are contaminated with blood. Children can be infected by an HCV-positive mother around the time of birth, and no treatment can prevent it. Children can also be infected by sharing a contaminated toothbrush of an HCV-positive family member or playmate. Infants who are infected with HCV at birth appear healthy during the first few years of life, however.

WHAT ARE THE SIGNS AND SYMPTOMS OF HCV INFECTION IN CHILDREN?

1. Most children with HCV infection have no symptoms.
2. Diarrhea often occurs in infected children.
3. Other symptoms include fatigue, aches, nausea, and weight loss.
4. Jaundice (a yellow discoloration) can be observed under the tongue, or in the outer layer of the eye (the sclera) in about 25% of HCV infected children.

HOW IS HCV INFECTION DIAGNOSED IN CHILDREN?
1. The children who should be tested for hepatitis C are: those born to HCV-positive mothers, those who are long-term hemodialysis patients, and those who received a blood transfusion or solid organ transplant before July 1992.
2. Blood tests for anti-HCV antibodies can be performed after a child is 12 months old.
3. A liver biopsy may be needed to determine the extent of liver damage.
4. PCR (polymerase chain reaction) molecular tests are not recommended for routine use in children.

HOW IS HCV INFECTION TREATED IN CHILDREN?
1. Combination therapy with interferon alfa and ribavirin is the best currently available treatment for adults who are infected with HCV.
2. This treatment is expensive, complex, ineffective, and has many serious side effects.
3. Seventy-five percent of HCV infected patients in the U.S. have the HCV-1 variant, which is very resistant to interferon alfa therapy.
4. Immune globulin is not effective for protecting patients after infection.
5. Antiviral drugs such as interferon and ribavirin, however, are not licensed for use in children under 18 years of age.

TIPS FOR PARENTS:
1. Pregnant women with HCV should not be treated with interferon. Ribavirin treatment causes birth defects, and pregnancy should be avoided during treatment.
2. About five percent of infants born to HCV infected mothers become infected at birth. The mode of childbirth (cesarean section versus vaginal delivery) is not related to the risk of transmission.
3. HCV RNA has been detected in breast milk of infected mothers.
4. HCV positive individuals should not share their toothbrush with others.
5. HCV positive individuals should practice strict hand washing procedures.

A recent issue of The New England Journal of Medicine included an editorial on hepatitis C. The article reviewed the natural history of HCV, current treatment regimens, the terminology of treatment, the recently improved formulation of interferon alfa, problems with current interferon therapy, and progress in the management of HCV.

Schafer DF, Sorrel MF: Conquering hepatitis C, step by step. The New England Journal of Medicine. December 7, 2000 343(23).

Dental Health For Children With Mental Retardation see photo
There are approximately 6 million individuals in the United States who have mental retardation, comprising 2.5 % of the population. An estimated 12 of every 1,000 U.S. school children have mental retardation. Mildly affected individuals comprise about 87% of all cases. Nearly twice as many males as females are affected.

Mental retardation is a consequence of a disorder affecting the central nervous system, as well as a symptom of other disorders. Mental retardation is defined as below-average intellectual functioning with an impaired ability to adapt to the environment. Mental retardation is defined by the American Association of Mental Retardation as an IQ (intelligence quotient) of 70 to 75 or below, and occurs before the age of 18.

Mental retardation is characterized by a delayed pattern of development. Affected children have problems with language and communication when compared to normal children of the same age. Children with mild to moderate retardation are identified later in childhood when delays in language and play become apparent. Approximately 50% of mentally retarded children have emotional and behavioral problems, which are mostly caused by their poor communication skills.

The normal brain development of a fetus or child requires a precise sequence of neurological developmental events which are proliferative, migratory, and maturational in nature. A specific cause for mental retardation can only be found in 25% of cases. When the cause is known, nearly 75% of cases are due to prenatal factors. Perinatal factors, such as hypoxia at birth, account for approximately 10% of cases. Postnatal causes account for less than 10% of all cases.

CAUSES OF MENTAL RETARDATION:
1. Malnutrition - the most common worldwide cause.
2. Genetic (chromosome abnormality), such as Down syndrome, fragile X syndrome, trisomy 18, and Kleinfelter syndrome.
3. Infection, such as congenital toxoplasmosis, congenital rubella, meningitis, and congenital cytomegalovirus encephalitis.
4. Brain injury, such as intracranial hemorrhage, severe head trauma, and hypoxia. Any of these forms of brain injury can lead to cerebral palsy. Approximately two thirds of individuals with cerebral palsy also have mental retardation.
5. Metabolic disease, such as Tay-Sachs disease, phenylketonuria, Reye's syndrome, hypoglycemia, and congenital hypothyroidism.
6. Environmental toxins, such as drug or alcohol use during pregnancy.

Mental retardation can be prevented in 20 to 30% of cases. Preventive measures include: good prenatal care, genetic counseling, restricting alcohol intake during pregnancy, avoiding illegal drug use, practicing safe sex, providing childhood immunizations, providing care safety seats and seatbelts, and providing bicycle helmets for children.

HOME DENTAL CARE FOR CHILDREN WITH MENTAL RETARDATION:
1. Choose a well-lit location so that you can look into your child's mouth.
2. If your child is in a wheelchair, try placing the chair in the kitchen during oral hygiene procedures. Stand behind the wheelchair. Lock the wheels first, and if possible, tilt the chair back into your lap. Use your arm to brace your child's head against the wheelchair's head support area.
3. Another position for brushing the teeth is to lay your child down with the head on your lap.
4. No matter what position is used for brushing your child's teeth, remember to always support the head.
5. If your child is unwilling or unable to keep the mouth open during brushing, ask your dentist to show you how to use a mouth prop during oral hygiene procedures.
6. Give lots of praise while brushing your child's teeth.
7. Parents should help brush their children's teeth every day, after every meal.
8. 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.
9. 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.
10. 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.
11. 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.
12. 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.

A recent issue of Current Opinion in Pediatrics described the latest advances in identifying the genetic causes of mental retardation. The article defined mental retardation, discussed its prevalence, and reviewed its many genetic causes.

Chiurazzi P, Ooostra BA: Genetics of mental retardation. Current Opinion in Pediatrics. 2000, 12:529-535.

Holiday Safety For Children see photo
The holiday season is an exciting time, filled with joy and celebration. It is also a time of increased risk for children. During the holidays, children are more likely to be exposed to: choking hazards, toy hazards, electrical hazards, food hazards, decoration hazards, poisoning hazards, and other hazards. Injuries to children often occur when there is a lack of adequate planning and supervision. Most holiday injuries to children are preventable, so always supervise your child! Here are some safety tips for protecting children during the holidays.

CHOKING HAZARDS:
1. Think large when selecting toys for children younger than 3 years old. Make sure that all toys and toy parts are larger than your child's mouth to prevent choking.
2. Children can be seriously injured or killed by inhaling, swallowing, or choking on small objects, such as small toy parts, marbles, or small balls.
3. Keep uninflated or broken balloons away from children. A child under age 8 can choke or suffocate on uninflated or broken balloons.

TOY HAZARDS:
1. Throw away all toy packaging right away so that it doesn't become become a choking or suffocation hazard.
2. Make sure that no part of a toy can break off and be swallowed by a child.
3. Don't buy toys with metal parts for a baby or toddler. Watch out for toys with sharp points or edges.
4. Keep batteries away from children, since they are toxic if swallowed. Batteries are also a choking hazard for small children.
5. Remember that any ball with a diameter up to one and three-quarters of an inch can easily cause choking in a child.
6. Avoid buying toys that shoot small objects into the air, since they often result in eye injuries. These arrows, darts, or pellets are also a choking hazard for young children. Each year, about 25,000 children are treated for injuries caused by BB guns and pellet guns.
7. Avoid buying toys that make loud or shrill noises.
8. Avoid items that could cause poisoning. Buy crayons, markers, and paint sets that are labeled nontoxic.
9. A toy chest without a lid is the safest choice for toy storage. A toy chest can hurt a child's fingers or hands if the lid closes suddenly. If a toy chest has a lid, it should have safe hinges that it can stay open in any position. A small child can suffocate if trapped inside of a closed toy chest. The chest should also have ventilation holes to prevent suffocation if a child becomes trapped inside.

ELECTRICAL HAZARDS:
1. Place electrical outlet covers on all outlets to reduce the risk of electrocution for children.
2. Do not overload electrical outlets with too many lights or appliances.
3. Never place electrical cords under carpets or behind drapes.
4. Throw away any electrical wires that are cracked, frayed, or bare.
5. Move electric curling irons and hair dryers far away from any sink or bathtub which might have water in it.
6. Turn off all lights, space heaters, and electrical appliances before you go to sleep or leave the house.

DECORATION HAZARDS:
1. Avoid decorations that have sharp edges or small, breakable parts.
2. Always supervise children near candles or open flames.
3. Never use lighted candles near drapes, curtains, wreaths, or trees.
4. Never leave burning candles unattended. Blow out all candles before going to sleep or leaving the house.

POISONING HAZARDS:
1. Lock up household cleaning products. The top two categories of childhood poisonings include household products and cosmetics.
2. Ask visitors to store their medications in high cabinets, out of reach of children.
3. Mistletoe and holiday berries are poisonous if swallowed.
4. Poinsettias can cause stomach irritation.
5. Post the telephone number of the local poison control center in an accessible place.

OTHER HAZARDS FOR CHILDREN:
1. Strings or cords are involved in numerous accidental strangulation deaths of infants and children. Cords from blinds, crib mobiles, hood cords, and pacifiers can accidentally strangle a child.
2. When visiting friends who have a dog, do not leave your child alone with the dog.
3. When visiting friends, remember that their homes may not be child-proofed. Ask to see if accessible cabinets are free of toxic items and medicines.
4. When cooking at home, keep children away from the stove. Use the back burners if possible. Turn he handles of pots and pans inward so that children cannot reach them.

Almost 3,000 people choke to death every year in the United States. An article in Oral Surgery, Oral Pathology, Oral Medicine reviewed hazards associated with foreign body ingestion and aspiration in the dental office. It discussed patient-related factors, preventive measures in the dental office, and clinical management of foreign body ingestion or aspiration.

Zitzmann NV, Elsasser S, Fried R, Marinello CP: Foreign body ingestion and aspiration. December 1999 88(6)657-660.

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