Pediatric Dental Health

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Does Your Child Have A Sore Throat?see photo
Sore throat is a common problem in children, especially between the ages of 5 and 10. Sore throat is a leading cause of visits to the doctor, and is responsible for approximately 10 percent of children’s medical visits.

The main reason for the concern about sore throat is that untreated “strep throat” can occasionally cause rheumatic fever in children 2 to 18 years of age. For this reason, the examining physician’s main concern is to decide whether or not your child has “strep throat.”

COMMON CAUSES OF SORE THROAT IN CHILDREN:

Sore throat can be caused by either viruses or bacteria.
Most cases of sore throat are caused by viruses, and are part of a cold. In children younger that 2 years of age, almost all cases of sore throat (pharyngitis) are caused by a virus.
Sore throat caused by viral illness usually last 3 or 4 days. The causative viruses include: rhinoviruses, coronaviruses, influenza A and B, and the parainfluenza viruses.
About 25 percent of sore throat is caused by strep bacteria - usually group A beta-hemolytic streptococci (GABHS). GABHS “strep” throat is spread via respiratory droplets, through close contact with another person who has streptococcal pharyngitis.
In nearly 30 percent of cases, no infectious cause is found for pharyngitis in children, however.

WHAT ARE THE SYMPTOMS OF SORE THROAT?
Viral pharyngitis is generally a disease with a gradual onset. The symptoms of viral pharyngitis include: sneezing, nasal congestion, and cough.
Strep throat (GABHS) is uncommon in children less than 2 years old. The symptoms of GABHS include: very high fever (104 F / 40 C), chills, pain on swallowing, swollen lymph nodes of the neck, nausea, and absence of cough.

WHAT ARE THE CLINICAL SIGNS OF SORE THROAT?
The signs of viral pharyngitis include: a cough, runny nose, diarrhea, inflammation of the eyes, hoarseness, and absence of upper respiratory infection symptoms.
The signs of strep throat (GABHS) include: high fever, vomiting, a discharge from the tonsils, and enlargement of the lymph nodes of the neck.

HOW IS A SORE THROAT DIAGNOSED?
The only way to know whether sore throat is caused by strep bacteria or a virus is to do a throat culture or a rapid strep test.
It can take up to 48 hours to get the results from a throat culture, however.

WHAT IS THE TREATMENT FOR VIRAL SORE THROAT?
All cases of sore throat need supportive care to increase a child’s comfort and reduce the risk of dehydration.
For viral pharyngitis, treatment should be supportive, and include antipyretics (acetaminophen 15 mg/kg/dose PO every 6 hours) for pain and fever.

WHAT IS THE TREATMENT FOR STREP THROAT?
All cases of sore throat need supportive care to increase a child’s comfort and reduce the risk of dehydration.
Strep throat is the only form of pharyngitis for which antibiotics should be prescribed!
Penicillin is the treatment of choice for strep (GABHS) throat. A dose of 20mg/kg/day PO is taken three times daily for 10 days.
Once-daily amoxicillin 750mg PO for 10 days may also be effective.
Treatment with antibiotics for GABHS pharyngitis should be started within 9 days of infection to prevent the possible development of rheumatic fever.
A child who has been taking antibiotics for 24 hours for GABHS is no longer contagious.

WHAT CARE SHOULD PARENTS PROVIDE?
Adequate fluid intake is of vital importance for the prevention of dehydration. Cool liquids are preferred.
Give children’s acetaminophen for sore throat, and when fever exceeds 102 degrees F (39 degrees C).
Children should avoid school or daycare for 24 hours after starting antibiotic therapy for GABHS. This will limit the spread of infection to other individuals who have not been exposed.
Call your child’s physician if there is drooling, difficulty swallowing, or difficulty breathing.

A recent article in The New England Journal of Medicine reviewed the topic of acute pharyngitis. It discussed the causes including: streptococcal pharyngitis, diphtheria, other bacterial infections, and viral infections.

Bisno AL: Primary care: acute pharyngitis. The New England Journal of Medicine. 18 January 2001; 344(3):205-211.

Is Your Child Hearing Impaired?see photo
About one out of every thousand newborns have profound or severe hearing loss. About three times as many infants are born with mild to moderate hearing loss. Another 3/1000 children develop hearing loss during childhood.

The ability to develop speech is directly related to the ability to hear sounds. The first year of life is very important for language development. The goal of treatment is therefore to enhance the process of language development as early as possible.

WHAT ARE THE TYPES OF HEARING IMPAIRMENT?
Conductive hearing loss is caused by a mechanical problem in the ear. It is the most common type of hearing problem in children. This type of hearing loss is often caused by earaches (otitis media).
Sensorineral hearing loss occurs when there is damage to the inner ear, or neural portions of the hearing mechanism. The most common disease affecting the inner ear is loss of the hair cells of the cochlea.

WHAT CAUSES HEARING IMPAIRMENT IN CHILDREN?
Disease in any part of the hearing system can cause hearing loss in children.
Repeated ear infections may lead to permanent hearing loss.
Malformations of the external auditory canal and middle ear can cause conductive hearing loss.
A benign tumor, called a cholesteatoma, can result in significant conductive hearing loss.
Acquired sensorineural hearing loss can be caused by many factors such as: bacterial meningitis, viral infections, loud noises, head trauma, or autoimmune disorders. Mumps is a frequent cause of unilateral hearing loss.

HOW IS HEARING IMPAIRMENT DIAGNOSED?
All infants and children should be screened for hearing loss as early as possible so that treatment may be started as soon as possible.
The birth admission hearing screen is performed on newborns before their discharge from the hospital. Severe bilateral hearing loss is usually diagnosed during the first week of life when the newborn does not respond to voices or sounds.
Tympanometry is used to help diagnose the cause of conductive hearing loss. This test does not require the active participation of the child. The testing device consists of a sound source and a microphone which are placed in the ear canal for a few seconds.
Acoustic reflex testing uses a similar device, and measures the contraction of the tiny stapedius muscle of the middle ear.

HOW IS HEARING IMPAIRMENT TREATED?
Conductive hearing loss can be improved by surgical drainage of ear fluids (myringotomy), or by a hearing aid.
Sensorineural hearing loss can be treated by hearing aids.
Children with profound bilateral hearing loss are candidates for a cochlear implant. The cochlear implant is fairly complex, and uses electrodes which stimulates the auditory nerve of the cochlea.

HOW CAN YOUR CHILD’S DENTIST HELP?
Avoid delays in starting dental treatment.
Keep dental procedures fairly short.
Invite a parent into the dental operatory to help with communication.
Don’t wear the protective mask when speaking to the hearing impaired child.
Reduce background noise and music during the appointment.
Explain to the child what will be done, and demonstrate some of the instruments that will be used.
The dentist should consider learning some basic hand signs to improve communication.
The dental staff should be sensitive to the child’s non-verbal communication.

An article in the British Dental Journal reviewed the topic of hearing impairment in children, and recommended some techniques for improving communication with hearing impaired children.

Champion J, Holt R: Dental care for children and young people who have a hearing impairment. British Dental Journal. August 2000; 189(3) 155-159.

Does Your Child Have Dental Erosion?see photo
Dental erosion is a major cause of tooth surface loss in children. Approximately 30 % of the primary molars of 5-year-old children are affected by erosion.

Erosion is the chemical dissolution of dental hard tissue by acids. The sources of acid causing erosion are: dietary, gastric reflux, and environmental.

The first sign of dental erosion in children may be a slight loss of surface luster on the front teeth. Teeth affected by chemical erosion become rounded and loose their surface anatomy. Dental erosion may cause tooth sensitivity, an altered dental bite, or even a dental abscess.

Dentists often suggest that patients brush their teeth immediately after consuming soft drinks or juices, but this is wrong - and may actually increase tooth surface loss! The worst time to consume a soft drink or fruit juice is right before bedtime toothbrushing. That’s because the acids in the beverage dissolve the enamel, which is then abraded away by the toothbrush.

WHAT CAUSES DENTAL EROSION IN CHILDREN?
All acids are capable of causing dental erosion.
The primary causes of dietary erosion are acidic beverages such as: soft drinks, carbonated beverages, fruit juices, and sports drinks.
Soft drinks are a cause of tooth surface loss in about 40 % of cases. The acids in sodas slowly dissolves the enamel of children's teeth.
Soft drinks are very destructive to children's teeth. Many of them contain not only processed sugar, but also carbonic acid, citric acid, and phosphoric acid.
Citric acid, found in most soft drinks and sports drinks, is very erosive. Citric acid is unusually damaging to children’s teeth because because of its destructive chelating effect on the enamel, which continues even when the oral pH rises.
The reduced thickness and increased solubility of children’s enamel contributes to dental erosion.

WHAT IS THE ROLE OF GASTRIC REFLUX IN TOOTH SUFACE LOSS?
Gastric acid caused by gastro-esophageal reflux disease (GERD) is another cause of dental erosion.
The dental erosion problems are caused by the acidic stomach contents, which travel back up into the oral cavity.
During a child's dental examination the dentist will see "dished-out" areas of lost enamel on the front of the incisors and eye teeth - near the gum line. These are also called cervical lesions of the labial surfaces. A flattening of the cusp tips of the primary molars may also be seen.

HOW IS DENTAL EROSION DIAGNOSED IN CHILDREN?
First, the dentist obtains a dietary history. This history determines the extent, frequency, and timing of acid consumption in a child’s diet.
Second, the dentist obtains a medical history. This history will help to determine if a child suffers from GERD, which can also cause dental erosion in young children.
Next, the dentist elicits the patient’s chief concern (chief complaint). The chief complaint might be: tooth sensitivity, chipping of teeth, pain in the teeth, or greying of the incisal edges of the front teeth.
The dentist then performs a clinical examination of the teeth. The exam may show: dental pulp exposure, a loss of surface antomy, a loss of tooth enamel, “cuspal cupping” or “dished-out” lesions of the enamel on the back teeth, or increased translucency of the incisal edges of the front teeth.
The first sign of erosion may be sensitivity or fracturing of the incisal edges of the front teeth.

HOW CAN YOU PREVENT DENTAL EROSION?
Don’t brush your teeth right after consuming a soft drink or fruit juice. Brushing at that time will simply increase tooth surface loss.
Don’t drink soft drinks or fruit juice just before bedtime toothbrushing.
Try to consume acidic beverages only with meals.
Avoid drinking soft drinks, sports drinks, and other acid-containing beverages immediately following exercise. Salivary flow is reduced after exercise, and the buffering action of saliva is therefore also decreased. The bicarbonate in saliva acts to buffer teeth from the destructive effects of acid.

WHAT IS THE TREATMENT FOR DENTAL EROSION IN CHILDREN?
The best way to manage erosion is to prevent it.
The goals of treatment are: to protect the exposed dentin and remaining tooth structure, control discomfort (hypersensitivity), and protect the dental occlusion.
Deciduous (baby) incisors are sometimes not treated (restored) because of a child’s limited ability to cooperate during treatment. Root canal treatment (pulpectomy) may be necessary if the nerve (dental pulp) is exposed or infected.
Deciduous molars are usually restored with stainless-steel crowns to increase comfort and halt tooth surface loss.
The permanent teeth of children and adolescents may be temporarily restored with composite resin.

An article in Pediatric Dentistry reviewed the literature on dental erosion in children. It discussed the prevalence, clinical signs, and causes of dental erosion in children. It recommended that children with dental erosion should be evaluated to identify the source of acids causing the erosion.

Linnett V, Seow WK: Dental erosion in children: A literature review. Pediatric Dentistry. January 2001; 23(1): 37-43.

Dental Health For Children With Down Syndrome see photo
Down syndrome is one of the most common genetic syndromes. It occurs in about one of 800 live births, and affects over 250,000 people in the United States. The facial expressions and oral problems of children with Down syndrome are unique and characteristic.

Approximately 95 percent of Down syndrome children have an extra copy of chromosome 21, which makes their chromosome count 47 - instead of the normal 46. Children with Down syndrome (DS) have varying degrees of intellectual impairment. There is often a severe delay in language development. More than 50 percent of children with DS will live past the age of 50.

WHAT CAUSES DOWN SYNDROME?
In 95 percent of cases, the syndrome is caused by an extra copy of chromosome 21, which failed to separate (nondisjunction) at the time of egg or sperm formation.
In 4 percent of cases, Down syndrome (DS) is caused by the attachment of an extra copy of chromosome 21 to another chromosome (translocation).
The remaining 1 percent of DS cases are a mosaic of normal and abnormal cells which are produced after conception (mosaicism). The result is that some cells have 46 chromosomes (normal) and some have 47 (abnormal).

HOW IS DOWN SYNDROME DIAGNOSED BEFORE BIRTH?
Serum multiple-marker testing is recommended for all low-risk pregnant women at 15-18 weeks of pregnancy. This test can detect 80 percent or more of Down syndrome pregnancies.
The chorionic villus sampling and amniocentesis procedures are tests which provide fetal cells whose chromosomes can be analyzed. These two procedures are reserved for women with a high-risk of having children with genetic abnormalities. Since these two procedures are invasive, they increase the risk of damage to the fetus.

HOW IS DOWN SYNDROME DIAGNOSED AT BIRTH?
At birth, the diagnosis of Down syndrome (DS) is based on examination of a child’s physical features, as well as the identification (karyotyping) of chromosomal abnormalities in the cells.
A newborn with DS will often have a flaccid (hypotonic) musculature.
Upslanting of the eyes (oblique palpebral fissures) is present in 70 to 98 percent of DS children.
Congenital heart defects occur in 40 to 50 percent of newborns with DS. The most common cardiac problem is a complete atrioventricular canal defect.

WHAT INCREASES THE RISK FOR DOWN SYNDROME?
Women over the age of 35 have a substantially increased risk of conceiving a child with a genetic abnormality.
If one parent has a chromosome 21 translocation abnormality, or if the first child has Down syndrome caused by a translocation of chromosome 21, then the risk of having a second child with this syndrome is dramatically increased.

ORAL AND CRANIOFACIAL FEATURES IN DOWN SYNDROME:
Upslanting of the eyes (upward-slanting of the palpebral fissures).
Closely-set eyes (hypotelorism).
An extra fold of skin towards the inner aspect of the eyes (epicanthal folds).
Downward slanting of the corners of the mouth.
The muscles of the lower lip are hypotonic, causing the lower lip to be everted.
A relatively enlarged tongue (relative macroglossia). This may be due to the fact that DS children have a small oral cavity and a narrow palate.
A narrow palate, which is due to the sides of the palate being abnormally thick.
Bruxism is common.
More than 90 percent of DS children develop fissures in their tongue by the age of 5. This may be due to developmental causes as well as chronic mouth breathing.
An open bite. This open mouth posture is due to relative macroglossia and mouth breathing. Mouth breathing is caused by having a small nasal airway.
Smaller-than-usual oropharyngeal and nasopharyngeal airway size.
About 13 percent of children with DS have increased mobility of the cervical spine (atlantoaxial instability). This problem precludes participation in contact sports for the affected individuals.

DENTAL FEATURES IN CHILDREN WITH DOWN SYNDROME:
Dental malocclusion and malalignment, including: cross bites, mandibular prognathism, and anterior open bite.
Lower-than-average incidence of dental caries.
High incidence of periodontal disease, beginning in the teen years. This is due in great part to the compromised immune system of the DS child.
Primary and permanent teeth are missing (congenitally) in 50 percent of DS children.
Hypoplasia and hypocalcification of teeth occurs often.
Very small (microdontic) teeth are present in 35 to 55 percent of the primary and permanent teeth of DS children.
Delayed eruption of teeth in 75 percent of cases. The delay in eruption may last as long as two to three years. The delay is partially due to thyroid disease.

THE ROLE OF THE DENTIST:
Try to schedule appointments for children with Down syndrome (DS) early in the day.
Obtain the child’s medical history before the first appointment so that any necessary medical consultations can be arranged.
Try to develop a good rapport with the child.
Gain the cooperation of the DS child by using behavior management techniques such as: tell-show-do, positive reinforcement, voice control, mouth prop, and general anesthesia.
Instruct the parent on proper home dental hygiene procedures.
Counsel parents about growth and development of the teeth and orofacial structures.
Provide relevant dietary counseling.
Offer myofunctional therapy for young children who have orofacial and tongue hypotonia. This treatment may increase the muscle tone of the lips, as well as keep the tongue inside of the mouth. The name of this treatment is: Castillo-Morales’ Orofacial Therapy.
Be aware that most children with DS have a decreased number of T cells in their immune system. This is what causes a high rate of oral infections and periodontal disease.
Diagnose and treat periodontal disease, especially in DS teens. Consider scaling and root planing the teeth as often as every three months to prevent the progression of periodontal disease. Chlorhexidine gluconate mouth rinse may be beneficial.
Obstructive sleep apnea (OSA) occurs in 54 to 100 percent of DS children. OSA precludes routine in-office sedation for many children with DS.
Avoid manipulation of the neck of DS children who have atlanto-axial (cervical spine) instability.
Provide antibiotic prophylaxis against subacute bacterial endocarditis (SBE) for children with heart defects. Note that a complete atrioventricular canal defect is common in infants, and mitral valve prolapse is common in young adults with DS.

HOME DENTAL CARE FOR CHILDREN WITH DOWN SYNDROME:
Choose a well-lit location so that you can look into your child's mouth.
No matter what position you are using for brushing your child's teeth, remember to always support the head.
Give lots of praise while brushing your child's teeth.
Parents should help brush their children's teeth every day, after every meal.
Brush the tongue. This will help prevent halitosis.
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.
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.
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.
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.
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.

An article in Pediatrics provides guidelines to assist pediatricians in caring for children with Down syndrome. The article was organized into six age-related areas, beginning with the prenatal visit, and ending with health supervision for adolescents and young adults.

American Academy of Pediatrics Committee on Genetics: Health supervision for children with Down syndrome. Pediatrics. February 2001; 107(2), 442-49.