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Flashcards in Pediatric Oral Disease Deck (112):

what primary teeth erupt first?

-central and lateral incisors usually toward the end of the 1st year of life
-then 1st molars
-then filling in around these areas w/ canine (cupsid)
-last 2nd molars


what order do primary teeth typically shed?

*roughly same order as they erupt
-central and lateral incisors usually toward the end of the 1st year of life
-then 1st molars
-then filling in around these areas w/ canine (cupsid)
-last 2nd molars


At what age and in what order do permanent teeth come in?

-First molar (6-7 years of age, often first to erupt but does not displace a primary tooth right away)
-Central incisor (7-8 years)
-Lateral Incisor (8-9 years)
-Canine/cuspid (9-12 years)
-First premolar (10-12 years)
-Second premolar (10-12 years)
-Second molar (11-13 years)
-Third molar/wisdom teeth (17-21 years), most times do not erupt
-Final molars come in around 6th-8thgrade, except wisdom teeth


when do wisdom teeth (3rd molars) typically come in?

late adolescence or not at all


what age will these teeth first erupt? TOP:
central incisors-
lateral incisors-
canine (cupsid)-
First molar-
Second molar-

central incisors- 8-12 months
lateral incisors- 9-13 months
canine (cupsid)- 6-22 months
First molar- 13-19 months
Second molar- 25-33 months


what age will these teeth first erupt? BOTTOM:
central incisors-
lateral incisors-
canine (cupsid)-
First molar-
Second molar-

central incisors- 6-10 months**
lateral incisors- 10-16 months
canine (cupsid)- 17-23 months
First molar- 14-18 months
Second molar- 23-31 months


how many primary teeth do we have?

-10 on top and 10 on bottom


In order for a primary tooth to shed, the permanent tooth must be positioned ____

more or less above the root of the primary tooth and this positioning erodes the primary tooth’s root

*important in preventing retained primary teeth or ectopic eruptions


what permanent teeth are often the first to erupt but does not displace a primary tooth

first molars
*erupt at age 6-7


when are eruption hematomas most common

during eruption of the 1st molar


what are ectopic eruptions?

eruption of a tooth not along its usual path
-ex. if a mandibular arch was too small to accommadate ones central incisors they can pop up behind the primary teeth--> this requires extraction of baby teeth and likely braces as an adult

*additional holes left in gingiva can be problematic


what is ECC

Early childhood caries (ECC) is defined as a caries (repaired or not) or missing teeth from caries in a child less than 6 y/o.


what is the number 1 chronic disease in children?

*greater than asthma!


how does decay occur (as seen in ECC)

Decay develops when Strep mutans bacteria grow in the presence of oral sugars, and the acid the bacteria produces erodes the tooth enamel. As the bacteria multiply, the teeth develop a biofilm, which becomes plaque, when then hardens into tartar.


what are the components of ECC prevention

1. strengthen enamel
2. reduce oral sugars
3. reduce transmission of strep mutans
4. manual removal of biofilm


what does the AAPD recommend in regards to fluoride

to fluoridate community water supplies as an effective means to reduce dental caries.
-The amount of fluoridation depends on the community and water testing may be necessary to determine if a child should receive additional fluoride supplementation after age 6 MONTHS


what are other sources of fluoride?

-bottled water w/ fluoride
-PCP can apply fluoride varnish 2x yr
-some through swallowed toothpaste
-Don't use fluoride mouthwash until age 4-5 when they can reliably spit

*fluoride toxicity is not really an issue unless they eat the whole tube


when can fluoridated mouth rinses be used?

Not until age 4-5 when they can spit reliably


what are the roles of fluoride

1. remineralization of enamel (strengthen enamel)
2. may arrest or reverse early caries
3. inhibit growth of cariogenic bacteria, thereby decreasing acid production
*mostly topical effectiveness


The breakdown of CARBS in the oral cavity by ____ produces ____ which demineralizes the teeth

Strep mutans
an acid (persists for 20-40 minutes after eating)


what should you counsel on regarding reducing oral sugars?

1. freq. of carb ingestion is more important than quantity (provide 3 meals and 2 snacks per day so oral cavity is not constantly infused w/ carbs and then acid)
2. stop bottle by age 1
3. no bottles or sippy cups for naps/bedtime (unless water)
4. limit milk to mealtime (at-will sippy cups should be water)
5. less than 6oz juice/day
6. limit soda and sweets


how do you delay/reduce transmission of strep mutans?

-don't share utensils or drinks w/ young children
-don't hold kids pacifiers in their mouth
-encourage good oral health for parents


how do you counsel caregivers about cleaning teeth/ manual removal of biofilm?

1. start in infancy by cleaning gums w/ small washcloth
2. use wash cloth when teeth begin to erupt and then a baby toothbrush
3. Caregivers should brush their kids teeth until 8y/o
4. floss 1x day when teeth begin to touch
5. see dentist by age 1 and then every 6 months


what are dental sealants used for?

-prevent caries by filling in the fissures on the chewing surface of the tooth
-80% effective in preventing cavities


what teeth can dental sealants be applied to?

non-carious molars
*If the molar has a cavity, the resin filling placed in the restoration process will act like a sealant

*must be applied by dentist but can last several years


Caregivers should be encourages to start early to decrease non-nutritive sucking, which includes fingers, pacifiers, bottles, etc. Ideally, these items would be removed by ____ as toddlers develop attachment behaviors to items and this increases the difficulty in getting them to stop a sucking habit.
-Tips for stopping include ___

age 1 (definitely by age 3!!!!)
-taking it away
-chili sauce (most often applied to fingers)
-discontinuing bottles and pacifiers around 9 months-1 yr


what are the consequences of prolonged sucking habits?

1. anterior open bite
2. increased overjet


what age is oral thrush (candidiasis) most often seen in

young infants and can occur in children up to 2 yrs
*after 2 you should start thinking about immunocompromised disease state


how does oral candidiasis/thrush present?

-white curd-like plaques initially beginning on the buccal and/or labial mucosa and spreading to the tongue and finally to the lips
-The exudate can be scraped off, but it doesn’t scrape off easily


complications associated w/ thrush

examine the diaper area as the fungus is swallowed and then excreted in the stool and often the infant has a candidial diaper dermatitis as well, which will also need treatment

*also consider non-benign condiitions like milk or formula powder


how do you treat oral candidiasis?

-Nystatin suspension orally for up to 4 weeks
-bottle nipples and pacificers need to be cleaned after use
-breastfeeding moms should apply small amount of nystatin suspension to their nipples (to prevent re-infection)
*if tx fails, consider Diflucan for 7 days


what is herpangina caused by

cocksackie virus

*same virus as hands, foot, and mouth -- but vesicular lesions are seen on hands, feet, and buttocks instead


when is herpangina most commonly seen and in who?

-in summer and fall months
-in children less than 6y/o, usually less than 3 yrs


symptoms of herpangina

-low grade fever
-vesicular/ulcerative lesions on the buccal, pharyngeal and/or labial mucosa


ddx of herpangina

-herpes gingivostomatitis


treatment of herpangina

-control of oral discomfort
-oral ibuprofen 10mg/kg/dose q6hrs until symptoms resolve (3-5 days)
AND/OR possibly
-3:1 mouth solution, KBX, magic mouthwash prescription
-OTC Zilactin or Orabase (form a sticky protective barrier over lesion to decrease pain)


what is in 3:1 mouth solution, KBX, magic mouthwash

*helps w/ herpangina
-The ingredients are 20cc each of the following: Benadryl, Maalox or Kaopectate, and may or may not include viscous lidocaine.
-Benadryl: controls inflammation
-maalox or kaopectate: a mucosal “band-aid” to keep salivary enzymes from irritating the lesions
-viscous lidocaine: numbing agent.
*Some providers prefer to leave out the viscous lidocaine due to possible toxicity in large quantities or numbing of the gag reflex.
*have strict instructions about applying the mouth solution using only a Q-tip and only on lesions that can be easily reached (this excludes the pharynx).


how is herpangina spread?

-highly contagious (mostly to young children bc adults have immunity)
-virus is in nasal and oral secretions

**Good handwashing is important!


what is the presentation of herpetic gingivostomatitis?

-children less than 8 years old
-usually very high fever
-often lasting 7-10 days
-vesicles and ulcers to pharyngeal, buccal and labial mucosa and most important: the GINGIVAL MUCOSA**
-significant cervical lymphadenopathy**
** (key in differentiating from herpangina)
*vesicles may spread to skin around mouth and nose
**minimally painful


what is herpetic gingivostomatisis caused by?

herpes simplex virus I


how do you treat herpetic gingivostomatisis

-usually self-limited
-oral ibuprofen and KBX if appropriate (7 days around the clock)
-avoid acidic beverages (OJ)
*oral acyclovir, an anti-viral drug, if symptoms have been present LESS than 72 hours (decrease duration of sx)


complications associated w/ herpetic gingivostomatisis

1. risk for dehydration due to oral pain
2. high fever and long in duration
3. ability for recurrence usually during times of illness or after sun exposure
4. eczema herpeticum (disseminated HSV infection from sucking on hands)
5. herpetic encephalitis
6. herpetic meningitis

*recurrence of HSV 1 usually consists of a solitary or possibly a few lip or lower face vesicular lesions, commonly known as a “cold sore” or “fever blister”--- never as severe as the initial infection


what is eczema herpeticum

disseminated HSV infection from sucking on hands
(superimposed HSV1 infection over eczema)


what should one consider if a child with HSV1 infection has a seizure?

herpetic encephalitis or meningitis


what is the presentation of glossitis

-areas of normal rough-appearing tongue mucosa with patches that appear denuded, smooth and shiny
-occurs commonly after a viral illness*, some medications, stress, and sensitizing foods such as citrus and tomatoes

*BENIGN and no need for treatment!
-can have chronic glossitis


what are apthous ulcers

Canker sores
-occur after minor mucosa trauma and can occur at any age


tx for apthous ulcers

-self-limiting in 7-10 days
-avoid irritating foods such as citrus and tomato-based products
-OTC zilactin or orabase are helpful in decreasing pain and speeding healing process


what are mucocele

-gelatinous fluid-filled cysts on the labial or buccal mucosa, which develop following trauma
**benign and do not need tx unless interfere w/ chewing-- refer to oral surgeon


what is ankyloglossia

aka tongue-tied
-a common congenital defect where the lingual frenum is attached very close to the tip of the tongue
*problems latching or sucking and possibly later speaking


how do you tx ankyloglossia

refer to ENT or oral surgeon to consider frenectomy (a procedure in which the frenum is resected and re-attached at a more appropriate location further back underneath the tongue)


what are 3 common oral anomalies in neonates

1. Bohn's nodules
2. Epstein's pearl
3. Dental lamina cyst

*all have different etiology but not require tx--resolve in a few weeks


where do bohn's nodules occur

occur along the buccal or lingual sides of the mandibular or maxillary gingival ridges as well as the hard palate


where do dental lamina cysts occur

can occur also along the crest of the mandibular and maxillary gingival ridges, but are more cystic in appearance than bohns nodules
*tx is not necessary


where do Epstein pearls occur

-only in the midline of the hard palate


what are the different parts of a tooth?

1. Crown- part about gumline, covered w/ shiny usually white enamel (but can vary)
2. Dentin- under enamel, dull/yellow
3. Periodontal membrane or peridontal ligament-anchors the tooth within the alveolar socket
4. tooth pulp- contains blood and nerve supply and keeps the tooth alive


what is dentin and why is it important

-contains multiple tubules which connect to the pulp of the tooth
-contains nerve endings which connect to the main nerves of the tooth located in the pulp
-as it can easily result in bacterial invasion of the tooth pulp when exposed, and this is somewhat more likely in children


what is the difference btwn Class 1, 2, 3, and 4 tooth fractures?

1-involve enamel layer only, benign
2-involve enamel and dentin layer, -- on PE see dull yellow dentin
3. involve enamel, dentin, and tip of pulp-- on PE see red dot on exposed pulp surrounded by dull yellow dentin
4. involve root of tooth-- PE could have wiggly tooth if under gumline


what is the management in Class 1, 2, 3, 4 tooth fractures for PRIMARY (deciduous) teeth

1- 2-3day DDS referral --> aesthetic repair
2- 2-3 day DDS referral --> resin filling used for restoration
3 or 4- Immediate DDS referral--> possible root canal vs extraction


what is the management in Class 1, 2, 3, 4 tooth fractures for SECONDARY (permanent) teeth

1- 2-3day DDS referral --> aesthetic repair
2- 2-3 day DDS referral --> resin filling used for restoration
3 or 4- Immediate DDS referral--> possible root canal/crown

*permanent teeth managed a bit more aggressively than primary (could do crown for class 1 or 2 fractures as well


types of teeth displacements that may occur secondary to trauma

1. avulsion
2. extrusion
3. intrusion
4. laxation

*Most common age is 3-4 years old--Falls, sports injuries, biking accidents


tooth has been traumatically REMOVED from socket

*tooth may be aspirated -- consider CXR to r/o if no tooth present
*may need dental xray to differentiate from intrusion


tooth has been PULLED DOWN in the socket



tooth has been PUSHED INTO socket


*need dental x-ray (by dentist)


tooth has been MOVED LATERALLY in the socket



The two important points about primary care initial management of dental displacements is:

1) recognition that the peridontal ligament of a permanent tooth needs protection if the tooth is to be viable after treatment
2) there is a developing permanent tooth under a baby tooth that is displaced, which must be protected sometimes at the expense of the baby tooth


For both primary and secondary dentition with intrusion and luxation injuries, the dentist will evaluate for a __ or ___ and then these teeth can be ___ and ___, then monitored for viability as they heal.
-As ____ sometimes is compromised, the tooth may turn dark or abscess later

root or alveolar socket fracture

repositioned and splinted

the pulp


Extrusions of permanent teeth can be____, but this is sometimes not the case with a baby tooth due to ____


risk to the developing permanent tooth with significant manipulation in the repositioning process


when might it be necessary from a primary care point to pull a extruded tooth?

if the injury and age of the child present a risk for aspiration (esp. under 2 y/o)

-then the injury is considered an avulsion


what is the management for
in PRIMARY (deciduous) teeth?

-Intrusions and Luxations: immediate DDS referral
-Extrusions: immediate DDS referral
-Avulsions: immediate DDS referral -- DO NO REINSERT!


what is the management for
in SECONDARY (permanent) teeth?

-Intrusions and Luxations: immediate DDS referral
-Extrusions: immediate DDS referral
-Avulsion: don't touch or scrub root. Rinse and re-insert less than 60 min. can store in milk/saline. immediate DDS referral


how to tx a tongue laceration

-rinse mouth w/ salt water after eating and expect closure by secondary intention in ~1 week
-suture w/ silk if severed or uncontrolled bleeding (difficult- like suturing jello)


how to tx a lip laceration

-An open lip laceration, where the lip has been opened through the vermillion border and up into the facial skin will need to be sutured to include closure of the facial skin and the vermillion portion of the lip up to the point where the vermillion portion meets the labial mucosa
-The mucosa can be left open
-oral abx if the laceration is from from the labial mucosa side through the skin (through and through)
-Any mucosal laceration left open will need to be rinsed with salt water after eating
*possible plastic surgeon consult if at vermillion border


anticipatory guidance to prevent dental or soft tissue oral injuries

-use of seatbelts, car seats
-mouth guards
-helmets w/ face guards


what is the tx of commissure burns

-immediate dental referral to be fitted for commissure split, which prevents the mucosal layers from touching and healing w/ fusion of the corner of the mouth (can effect speech, feeding, and looks)


what is the primary care providers role in commissure burns?

-debride the burn tissue
-provide abx prophylaxis
-verify tetanus immunization
-refer to dentist or oral surgeon for commissure splint


what teeth can typically be missing?

-3rd molars
-the maxillary lateral incisors
- the mandibular 2nd premolars


what is Anodontia

absence of teeth, occurs when no tooth buds form (ectodermal dysplasia, or familial missing teeth) or when there is a disturbance of a normal site of initiation (the area of a palatal cleft)


what is supernumerary teeth

-when the dental lamina produces more than the normal number of buds
-most often in the area between the maxillary central incisors
-occurs with cleidocranial dysplasia


2 teeth are joined together, is most often observed in the mandibular incisors of the primary dentition. It can result from gemination, fusion, or concrescence.



the result of the division of 1 tooth germ to form a bifid crown on a single root with a common pulp canal; an extra tooth appears to be present in the dental arch.



the joining of incompletely developed teeth that, owing to pressure, trauma, or crowding, continue to develop as 1 tooth.
-sometimes joined along their entire length; in other cases, a single wide crown is supported on 2 roots.



the attachment of the roots of closely approximated adjacent teeth by an excessive deposit of cementum. This type of twinning, unlike the others, is found most often in the maxillary molar region



represents a group of hereditary conditions that manifest in enamel defects of the primary and permanent teeth without evidence of systemic disorders
-Susceptibility to caries is low, but the enamel is subject to destruction from abrasion

Amelogenesis imperfecta


a condition analogous to amelogenesis imperfecta in which the odontoblasts fail to differentiate normally, resulting in poorly calcified dentin
-autosomal dominant

Dentinogenesis imperfecta, or hereditary opalescent dentin

*common in those w/ osteogenesis imperfecta


when do neo- and natal teeth typically arise

natal- birth
neonatal ~1 month old


how many teeth does an adult usually have

32 total
maxillary: 16
Mandibular: 16


____ is the most cariogenic sugar because one of its by-products during bacterial metabolism is ___, a polymer that enables bacteria to adhere more readily to tooth structures




Traumatic oral injuries may be categorized into 3 groups:

1. injuries to teeth
2. injuries to soft tissue (contusions, abrasions, lacerations, punctures, avulsions, and burns)
3. injuries to jaw (mandibular and/or maxillary fractures)


Injuries that produce minor damage to the periodontal ligament



mild to moderate horizontal mobility and/or vertical mobility. Hemorrhage is usually evident around the neck of the tooth at the gingival margin

sublaxated teeth


-ulcers are characterized by well-circumscribed, ulcerative lesions with a white necrotic base surrounded by a red halo
-lasts 10-14 days

aphthous ulcer


Painful; lesions confined to soft palate and oropharynx



Painful; lesions on tongue, anterior oral cavity, hands, and feet

hand, foot, and mouth disease


Vesicles on mucocutaneous borders; painful, febrile

Herpetic gingivostomatitis


Vesicles on lips; painful

Recurrent herpes labialis


-gingiva becoming erythematous, mucosal hemorrhages, and clusters of small vesicles erupting throughout the mouth
-oral symptoms generally are accompanied by fever, lymphadenopathy, and difficulty eating and drinking

Herpetic Gingivostomatitis


These lesions arise from epithelial remnants of the dental lamina

dental lamina cysts


These lesions arise from remnants of mucous gland tissue

bohn nodules


~80% of adults have multiple yellow-white granules in clusters or plaque-like areas on the oral mucosa, most commonly on the buccal mucosa or lips
-they are aberrant sebaceous glands.

fordyce granules


a soft reddish papule located adjacent to the root of a chronically abscessed tooth. It occurs at the end-point of a draining dental sinus tract

parulis (gum boil)


dryness of the lips followed by scaling and cracking and accompanied by a characteristic burning sensation that is common in children (associated w/ fever)



a benign and asymptomatic lesion and is characterized by 1 or more smooth, bright red patches, often showing a yellow, gray, or white membranous margin on the dorsum of an otherwise normally roughened tongue

Geographic tongue (migratory glossitis)


malformation manifested clinically by numerous small furrows or grooves on the dorsal surface

fissured tongue (scrotal tongue)


what do the following derive from:
Bohn Nodules
Epistein Pearls
Dental lamina cysts
Fordyce granules

mucous gland= bohn nodules
epithelial gland= epistein pearl
dental lamina= dental lamina cyst
fordyce granules= aberrant sebaceous glands


where does twinning most commonly occur

Mandibular incisors


Where does concrescence most commonly occur

maxillary molar region (unlike most other forms of twinning which occurs by mandibular incisors)


where does gemination most commonly occur

dental arch (appears to have an extra tooth bc 1 bud forms 2 crowns)


diarrhea, runny nose and fever _____ (are or are not?) due to teething, sometimes fussiness can be related to teething

are not due


infants suck for nutrition purposes to age ___, after that if considered non-nutritious sucking

6 months


Sealants are ___% effective in preventing caries



tx of glossitis

none needed (self limiting)
-parents should be reassured


Children age __ are prone to electrical injuries as they explore world with mouth

less than 3