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Children’s Dental Health: Overview for the Physician
Symposium on Oral Health
Children's Dental Health: Overview for the Physician Robert E. Miller, M.D., M.S. (Hyg.), * and David I. Rosenstein, D.M.D., M.P.H. f
Dental problems are very common and affect people of all ages. The physical and emotional discomfort, economic loss, and inconvenience can be significant. Primary care physicians providing health care for children can prevent morbidity resulting from dental problems. This article will discuss the preventive role of the physician after presenting an overview of the prevalence, etiology, morbidity, and preventive measures for the most common pediatric dental problems seen by the primary care physician: caries, periodontal disease, malocclusion, and dental trauma.
CARIES Tooth decay is the most common dental problem found in children. In fact, it is the most common health problem found in children. Children of all ages and social classes frequently present with caries. In a fluoride-deficient area, Hennon and Stookey found that 8.3 per cent of 18- to 23-month-old children had dental caries and that the prevalence increased to 57.2 per cent by 36 to 39 months. 30 Results of the Ten State Nutrition Survey show that tooth decay becomes more prevalent with increasing age. The average number of carious teeth for children five and six years of age were 3.7 arid 5.1 respectively. 12 A Public Health Survey in the late 1960's demonstrated an increasing decayed, missing, and filled (DMF) teeth ratio through the teenage years which leveled out in early adulthood. 39 An Indiana study found that less than 4 per cent of a group of high school students were free of dental decay and that there was a mean of two to three new carious lesions per student per year. 15 The National Center for Health Statistics reported an average of 1.1 missing teeth due to caries in 17-year-old adolescents. 39 The data from these studies clearly show that children of all ages visiting the physician will have experienced dental decay, and some will have suffered tooth loss. *Director of Pediatric Outpatient Services, Assistant Professor of Pediatrics, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland f Professor and Chairman, Department of Public Health Dentistry, University of Oregon Health Sciences Center, Portland, Oregon
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Dental decay is caused by the acid products from bacteria in plaque when refined sugars, especially sucrose, act as substrates. The more frequent or prolonged the direct contact of sugar with teeth, the greater the incidence of carious lesions. 26 • 72 This is believed to be due to a more frequent drop in the pH of bacterial plaque, allowing acid dissolution of teeth by bacteria. 67 A classic longitudinal study over a five-year period revealed that Swedish children consuming "sticky" sugars in candies such as caramel and toffee had a higher incidence of caries than children eating foods with less toothadhering sugars. 26 "Nursing bottle caries" is caused by repeated pooling of sweetened liquids or acidic foods around the primary teeth of preschool children when using the nursing bottle for extended periods. 23 Case reports have implicated milk, 18 • 38 sweetened juices, 35 pacifiers dipped in sugary substances, 73 and liquid medications. 19 Data for the latter are not as convincing as for the others. Development and progression of caries depend on location of the lesion, age, diet, and fluoride intake. At age two years, 6 per cent of caries are found in the molar occlusive surfaces, 25 per cent are located in the proximal smfaces of incisors, and 2 per cent are found in the proximal molar surfaces. With increasing age and changing patterns of tooth eruption, approximately 50, 10, and 30 per cent of carious lesions are found in the molar occlusive, incisor proximal, and molar proximal surfaces respectively. 54 The caries attack pattern is similar for the pennanent dentition. In children six to 12 years of age, the majority of carious lesions are found in the permanent six-year molars and least commonly in the maxillary permanent central and lateral incisors. The percentage of lesions in the incisors increases, while that of the molars decreases with advancing age. At age 8, approximately 1 per cent of incisors are carious, as compared with 10 and 15 per cent at ages 11 and 12 respectively. 42 As with the primary dentition, occlusive caries are more prevalent than the proximal type. At age 12, about 50, 30, and 20 per cent of caries involving permanent tooth surfaces are occlusive, proximal, and buccal respectively. 71 Grondahl reported that caries progressed more slowly in teenagers. Over a three-year period, only 10 per cent of previously normal tooth surfaces had developed caries that were confined to the superficial enamel.2 5 Fluoridation of community water is the most effective, safe, convenient, and economical method of preventing caries. The ingestion of the appropriate amount of fluoride in drinking water during the period of tooth calcification will result in a reduction of caries of 50 to 70 per cent. 9 The classic 10-year study by Ast comparing the incidence of carious lesions in children living in a fluoridated area and in a fluoride-deficient area in upstate New York showed that children in the fluoridated area had 60 per cent fewer carious lesions than those in the fluoride-deficient area. Reduction in caries was correlated with exposure time to 1 ppm of fluoride in the water. Children ingesting fluoride beginning in the immediate newborn period developed fewer carious lesions than those starting fluoride intake later. In addition, systemic fluoride has been shown to be effective in preventing lesions on the proximal tooth surfaces, which are the most difficult and costly to treat. 2 The effects of fluoride in preventing dental caries were demonstrated in a Dutch study. The initiation and progression of caries were shown to be slower in a group of
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children consuming adequate amounts of fluoride. In addition, the results suggested that there was some reversal of existing lesions. 44 Unfortunately, there are approximately 114 million people in the United States who do not reside in areas with adequate fluoridation of water supplies. 16 Fluoride tablets, 5 school water fluoridation, 32 fluoride mouthrinse, 61 or topically applied fluoride 32 should be implemented in areas where the water is fluoride-deficient as an alternative to fluoridation of community water. These alternative methods are more difficult to accomplish and are more expensive than fluoridation of community water; they result in caries reduction of approximately 20 to 60 per cent.
PERIODONTAL DISEASE
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Many studies have confirmed the high prevalence of gingivitis in children.48· 57 By age three, most Scandinavian children have gingivitis. 5 7 Depending upon the criteria used for diagnosis, from 0.06 to 44 per cent of teenagers have more serious periodontitis. 7 • 14 Using the Periodontal Index, the National Center for Health Statistics reported that 38.7 per cent of children 6 to 11 years old have periodontal disease. Most of the children had only mild gingivitis. Periodontal pockets, a sign of chronic disease and a more serious problem than gingivitis, were found in only 0.8 per cent of the children. 40 Other studies show that moderate to severe periodontal disease is uncommon in the pediatric patient. 5°· 63 There is a definite relationship between gingivitis and bacterial plaque at the gingival margin. In a study now regarded as a classic, Loe stopped all methods of oral hygiene. This allowed plaque to accumulate, causing gingivitis within several days. 49 In another study, Axelsson and Lindhe compared a group of children who had their teeth professionally cleaned every two weeks with a control group. After one year, they reported almost total disappearance of gingivitis in the experimental group but not in the control group. 3 These two studies demonstrate the importance of plaque in the etiology of gingivitis and the importance of oral hygiene in preventing both plaque accumulation and gingivitis. Limited data suggest that gingivitis in childhood may progress to periodontitis with possible tooth loss in adulthood. 47 • 65 However, there is also evidence to suggest that childhood gingivitis and adult periodontitis may not represent a continuum. Physiologic changes during puberty may cause a temporary exaggerated response to the existing level of inflammation from dental plaque, which may result in an apparent increase in prevalence and severity of gingivitis during this period. In a longitudinal study of gingivitis in adolescents 11 to 17 years of age, Sutcliffe reported that gingivitis tended to peak and then decline during a six-year period and that peak periods of gingivitis did not correlate significantly with peak periods of poor oral hygiene. 70 Additional evidence for an exaggerated inflammatory response of the gingival tissues to physiologic factors was demonstrated in a longitudinal study by Hugoson, who showed that increases in prevalence and severity of gingivitis in pregnancy were related to simultaneous changes in female sex hormones. 34 Samant and colleagues demonstrated that there was a significant
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increase in the severity of gingivitis during pregnancy and that gingival changes showed a greater correlation with the calculus and the debris index in the pregnant group as compared with the control group. 64 Although far from conclusive, these studies suggest that there may be a reversible inflammatory gingival tissue response to bacterial plaque during specific stages of life.
MALOCCLUSION Studies documenting the prevalence of malocclusion and the need for orthodontic treatment in children vary depending upon diagnostic criteria. American and European literature report the prevalence of malocclusion to be between 60 and 78 per cent in children aged six to 12 years. 27 • 62 The National Center for Health Statistics reported that in a study sample of American children aged six to nine, 75 per cent had malocclusion: 39 per cent had minor manifestations, 22 per cent could be treated electively, 8.7 per cent needed treatment sooner, and 5.5 per cent required urgent treatment. 41 In a later study, the National Center for Health Statistics found that 16 per cent of adults had severe malocclusion. 53 Such variables as premature loss of primary teeth, 43 • 55 thumb-sucking and/or finger-sucking, 5 1 • 56 • 69 tongue thrusting, 69 ethnic group, 6 and hypertrophied tonsils and/or adenoids, 68 have been thought to produce malocclusion. Convincing data exist for the first two variables. Significant deviation in the anterior dental arch with forward-protruding incisors, especially maxillary incisors (overjet type), has been demonstrated in children with persistent thumb-sucking habits as compared with controls.s'· 56 Popovich studied children with thrumb-sucking habits longitudinally from age three to 12 and found that the effects of thumb-sucking on malocclusion were transient if the habit was stopped before six years of age. All children continuing to suck their thumbs after age six had abnormal occlusion. 56 Studies by Kronfeld 43 and by Pederson and colleagues 55 show that premature loss of primary teeth can result in malocclusion owing to drifting of adjacent teeth with accompanying space loss. The presence of malocclusion has been said to have an adverse effect on a child's self-esteem, adjustment, and body image and may evoke ridicule and teasing from other children. 24 • 58 However, poor orofacial appearance is a subjective phenomenon and attitudes and feelings about such a disorder may vary among individuals. Howitt et al. examined the relationship between the presence of malocclusion and self-satisfaction with occlusion and found that dissatisfaction with teeth increased sharply in subjects with poorer orthodontic conditions. However, the investigators found that one third of those dissatisfied with their dentition had reasonably esthetic dentitions. 33 Baldwin and Barnes investigated the motivation for seeking orthodontic treatment. The dentofacial deformity was the primary motivating factor in less than 5 per cent of the families. Such motives as the resolution of family problems and status-seeking were frequent. When the children were asked why they came to the orthodontist, one half responded that their mothers and two thirds responded that one or both parents were the main reason for obtaining treatment. 4 The results of these studies reveal the importance of assessing
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each child and family carefully for possible psychological and social effects of malocclusion and for the reasons for seeking treatment.
DENTAL TRAUMA A fourth common problem seen in children is traumatic injury to the dentition. A number of studies have demonstrated that the prevalence of injured teeth may be 25 to 30 per cent by age 12.1. 20 Thirty per cent of a group of black, inner-city children aged three to six years attending a Head Start Program had traumatized primary incisors. The frequency of injury in this study was the same for males and females. The maxillary incisors were involved in 74 per cent of injured teeth. The peak age of injury was between four and five years. 20 Jarvinen reported the frequency of injury to permanent incisors to be 19.8 per cent, with a boy to girl ratio of 1.7 to 1, with the greatest frequency of injury occurring at nine to 11 years. As with injuries to primary teeth, the maxillary permanent incisors were most frequently injured. 36 The causes of dental trauma in a study of children six to 16 years were collision and bumps in 37 per cent, fighting in 8 per cent, sports participation in 6 per cent, accidents in 6 per cent, and unknown in 4 per cent. There were no significant differences in causes of dental injuries between sexes. 59 A causal relationship between the frequency and severity of injuries to permanent anterior teeth and malocclusion of the overjet variety has been reportedY· 37 • 46 In a group of Finnish children seven to 16 years, Jarvinen found the frequency of injuries to maxillary permanent incisors to be 14.2 per cent in children with no oveljet, 28.4 per cent in children with mild to moderate oveljet, and 38.6 per cent in children with severe oveijetP The frequencies of types of injury from trauma in a study of children ranging in age from nine months to six years were intrusion in 35 per cent, loosening in 25 per cent, exarticulation in 19 per cent, and luxation in 15 per cent. Fractures of the crown and the root accounted for only 3 per cent and 2 per cent respectively. It was significant that exarticulation almost always resulted in damage to the corresponding permanent tooth. Intruded primary teeth usually reerupted within six months, but they often interfered with the eruption of succeeding permanent teeth. 60 Andreasen reported that luxation was the most common injury to the primary dentition and uncomplicated fractures were the most common injury to the permanent dentition. 1 Injury to permanent teeth can result in a less attractive physical appearance and the need for restorative care. The use of mouth and face protectors, especially in sports such as football, hockey, and boxing, has greatly reduced orofacial injuries. When mouth and face protectors were not used by football players, 50 per cent of all injuries were to the orofacial area. 28 The face guard protects against direct blows to the orofacial area and the mouth guard protects against blows under the chin and to the top of the head, which may cause acceleration of the head, deformation of bone, and increased intracranial pressure. 31 A five-year study at Notre Dame showed that the use of mouth protectors in football players significantly reduced the incidence of concussions and neck injuries. 66 After requiring the use of mouth protectors, the Amateur Hockey Association reported a decrease
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in dental injuries in 15- to 19-year-olds from 8.3 to 0 per cent over a three-year period.U Since 1962, many organizations involving children and young adults in competitive sports, such as the National Alliance and the National Collegiate Athletic Association, require the use of mouth protectors.
THE PHYSICIAN'S ROLE Because there is no associated mortality or obvious serious physical morbidity, physicians may overlook the importance of dental problems in children. From the material presented, it is clear that dental problems can result in organic and psychosocial morbidity. In discussing morbidity, however, the pain, discomfort, anxiety, restriction of activity, and economic loss from dental disease must be considered. In 1972, dental costs for American families totaled over five billion dollars. 45 According to a study by the United States government, there were 5.6 days ofbed disability and 14.6 days of restricted activity per 100 persons per year, and 50 million school hours were lost in 1968 owing to dental disease. 10 The physician's role is to maintain optimal dental health by preventing morbidity. The main activities for the physician in dealing with preventive dental health for children are assessment, education, prescription of fluoride, and referral. The content of these activities relate to caries, periodontal disease, malocclusion, and dental trauma. The assessment consists of a good dental history and physical examination. Information should be elicited regarding frequency and type of dietary sugar intake, type and amount of fluoride consumption, types and extent of oral hygiene practices, thumb- and/or finger-sucking habits, and the use of face and mouth protectors. The physician should inquire about the frequency of visits to the dentist. The content of the physical examination should be based on a knowledge of what the physician can realistically detect. In a study by Finn, children received oral examinations by a physician, nurse and then a dentist. The physician found 67.1 per cent, the nurse found 66.2 per cent, and the dentist found 2.7 per cent of these children to be free of caries. 21 The use of special instrumentation, lighting, and x-rays by the dentist increases the sensitivity of caries detection, especially interproximal lesions. The use of dental x-rays can increase the yield by 50 per cent. 8 If the physician does not discover caries on the physical examination, this does not mean that the child is free of caries. The physician cannot be expected to know the need for orthodontic treatment for all degrees of malocclusion, since there is often disagreement among orthodontists over this issue. 29 With these limitations in mind, the physical examination should include a thorough inspection of the teeth and gums for caries, traumatized or missing teeth, malocclusion, and signs of gingivitis, especially in teenagers. The typical distribution of caries involving maxillary incisors and/or molars and sparing the mandibular incisors in a preschool child is diagnostic of the "nursing bottle caries syndrome." After assessing the child, education should be provided to the patient and family based on the effectiveness of specific preventive measures. The need
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for fluoride should be explained, and fluoride should be prescribed if the content of fluoride in the family's drinking water is deficient. Separate prescriptions for fluoride should be dispensed to all children under 13 years of age residing in a fluoride-deficient area. Caution should be exercised in dispensing fluoride in combination form with vitamins, since fluoride intake inadvertently may be stopped when the vitamins are discontinued. Methods of oral hygiene should be explained to parents and children, particularly children over the age of 10. Parents and children should be advised about the appropriate type and frequency of refined sugar intake. If thumb-sucking persists beyond age four or five, psychological issues may need to be explored and pedodontic or orthodontic referral may be necessary. Inappropriate nursing bottle habits should be discouraged. The importance of face and mouth protectors for sports participation, especially football, hockey, wrestling, and boxing, should be explained. One of the most important preventive tools available to the primary care physician is referral to a dentist experienced in treating children. Unfortunately, approximately 30 per cent of all children under 1722 and 46.8 per cent 13 of all children under 12 in the United States have never been to a dentist. This situation is worse for children from poor families. Children from families with an income of over $15,000 per year are almost three times more likely to have visited a dentist in the past year as children from families with an income of less than $13,000 a year. 5 2 This is reflected in data showing children from low income homes to be more likely to have decayed and missing teeth rather than restored teeth. 39 Referral should be made for specific problems detected in the assessment as well as for routine dental care beginning at about age 18 months to two years. Children with specific medical and physical problems, such as congenital heart disease, diabetes, and blood dyscrasias, have special needs for dental care. Primary care physicians who are sensitive to these needs can work closely with the dentist to provide optimal dental care for these children.
CONCLUSION Dental problems are the most common health problems affecting children. The primary care physician providing health care for children can prevent the physical, psychosocial, and economic consequences of carie~, periodontitis, malocclusion, and trauma by appropriate assessment, education, and referral of children to the dentist. Referral to a dentist experienced in dealing with children and ensuring adequate fluoride intake in children residing in fluoride-deficient areas are two important preventive measures available to the physician.
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3. Axelsson, P., and Lindhe, J.: The effect of a preventive programme on dental plaque, gingivitis and caries in school children. Results after one and two years. J. Clin. Periodontal., 1:126, 1974. 4. Baldwin, D. C., and Barnes, M. L.: Psychosocial factors motivating orthodontic treatment. J. Dent. Res., 44:461, 1965. 5. Binder, K., Driscoll, W. S., and Shuzmannsky, G.: Caries-preventive fluoride tablet programs. Caries Res., 12:22, 1978. 6. Bjork, A., and Helm, S.: Need for orthodontic treatment as reflected in the prevalence of malocclusion in various ethnic groups. Acta Socio-Med. Scand., Suppl. 1:209, 1969. 7. Blankenstein, R., Murray, J. J., and Lind, 0. P.: Prevalence of chronic periodontitis in 13-15 year old children. J. Clin. Periodontal., 5:285, 1978. 8. Blayney, J., R., and Greco, J. F.: The Evanston dental caries study. IX. The value of roentgenological vs. clinical procedures for the recognition of early carious lesions on the proximal surfaces of teeth. J. Dent. Res., 31:341, 1952. 9. Blayney, J. R., and Hill, I. N.: Fluorine and dental caries. J. Am. Dent. Assoc., 74 {special issue): 233, 1967. 10. Carlos, J.P.: Prevention and oral health. NIH U.S. DHEW. Pub!. No. (NIH) 74-707, Washington, D.C., U.S. Government Printing Office, 1975. 11. Castaldi, C. L.: Mouth guards in contact sports. J. Conn. State Dent. Assoc., 48:233, 1974. 12. Center for Disease Control: Ten-State Nutrition Survey 1968-70, Vol. Ill. Clinical, Anthropometry, Dental DHEW Pub!. No. (HSM) 72-8173. Atlanta, Georgia, Center for Disease Control, 1972. 13. Craig, T. T., and Montague, J. L.: Family oral health survey. J. Am. Dent. Assoc., 92:326, 1976. 14. Davies, P. H. J., Downer, M. C., and Lennon, M.A.: Periodontal bone loss in English secondary school children. J. Clin. Periodontal., 5:278, 1978. 15. Dennison, D.: Dental Health Instruction Project: Final Report, Ball State University, Indiana, August, 1973. 16. Dunn eng, J. M.: Principles of Dental Public Health, 3rd ed. Howard Press, 1979. 17. Eichenbaum, I. W.: A correlation of traumatized anterior teeth to occlusion. J. Dent. Child., 30:229, 1963. 18. Fass, E. N.: Is bottle feeding of milk a factor in dental caries? J. Dent. Child., 29:245, 1962. 19. Feigal, R. J., Jensen, M. E., and Mensing, C. A.: Dental caries potential of liquid medications. Pediatrics, 68:416, 1981. 20. Ferguson, F. S., and Ripa, L. W.: Prevalence and type of traumatic injuries to the anterior teeth of preschool children. J. Pedod., 4:3, 1979. 21. Finn, S. B.: Prevalence of dental caries. In Survey of the Literature of Dental Caries, Publication No. 225, Washington, D. C. National Academy of Sciences-National Research Council, 1952, pp. 117-173. 22. Givens, J.D.: Current estimates from the Health Interview Survey. Vital and Health Statistics; Series 10, No. 130, DHEW Pub. No. (PHS) 80-1551, Washington, D.C., Government Printing Office, 1972. 23. Goose, D. H., and Gittus, E.: Infant feeding methods and dental caries. Public Health, 82:72, 1968. 24. Graber, L. W., and Lucher, G. W.: Dental esthetic self-evaluation and satisfaction. Am. J. Orthod., 77:163, 1980. 25. Grondahl, H. G., Hollander, L., and Malmcrona, E.: Dental caries and restorations in teenagers, II. Swed. Dent. J., 1:51, 1977. 26. Gustafsson, B. E., Quenset, C. E., Lanke, L. S., eta!.: Vipeholm dental caries study. Acta Odont. Scand., 11 :232, 1954. 27. Heikinhermo, K.: Need of orthodontic treatment in 7 year old Finnish children. Community Dent. Oral Epidemiol., 6:129, 1978. 28. Heintz, W. D.: Mouth protectors: A progress report. J. Am. Dent. Assoc., 77:632, 1968. 29. Helm, S., Kreiborg, S., and Barlebo, J., eta!.: Estimates of orthodontic treatment need in Danish school children. Community Dent. Oral Epidemiol., 3:136, 1975. 30. Hennon, D. K., Stookey, G. K., and Mihler, J. C.: Prevalence and distribution of dental caries in preschool children. J. Am. Dent. Assoc., 79:1405, 1969. 31. Hickey, J. C., Morris, A. L., and Carlson, L. D., eta!.: The relation of mouth protectors to cranial pressure and deformation. J. Am. Dent. Assoc., 74:735, 1967. 32. Horowitz, H. S.: A review of systemic and topical fluorides for the prevention of dental caries. Community Dent. Oral Epidemiol., 1:104, 1973. 33. Howitt, J. W., Stricher, G., and Henderson, L.: Eastman esthetic index. New York Dent. J., 33:215, 1967. 34. Hugoson, A.: Gingival inflammation and female sex hormones. J. Periodont. Res., Supplement 5, 1970.
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35. James, P. M. C., Parfitt, G. J., and Falkner, F.: A study of the etiology of labial caries of the deciduous incisor teeth in small children. Br. Dent. J., 103:37, 1957. 36. Jarvinen, S.: Fractured and avulsed permanent incisors in Finnish Children. Acta Odontol. Scand., 37:47, 1979. 37. Jarvinen, S.: Incisal oveljet and traumatic injuries to upper permanent incisors. Acta. Odontol. Scand., 36:359, 1978. 38. Jenkins, G. N., and Ferguson, D. B.: Milk and dental caries. Br. Dent. J., 120:472, 1966. 39. Kelly, J. E., and Harvey, C. R.: Decayed, Missing and Filled Teeth Among Youths 12-17 years, Vital and Health Statistics: Data from the National Health Survey, Series 11, No. 144, DHEW Pub!. No. (HRA) 75-1626, 1974. 40. Kelly, J. E., and Sanchez, M.: Periodontal disease and oral hygiene among children, Vital and Health Statistics, Series 11, DHEW Pub!. No. (HSM) 72-1060, No. 130, June, 1972. 41. Kelly, J. E., Sanchez, M., and Van Kirk, L. E.: An assessment of the occlusion of the teeth of children 6-9 years. Vital and Health Statistics, Series 11, No. 130, 1973. Washington, D.C., Government Printing Office. 42. Klein, H.: The Epidemiology of Dental Disease. Collected papers, 1937-47. Washington, D.C., Federal Security Agency, U.S. Public Health Service, 1948. 43. Kronfeld, S. M.: The effects of premature loss of primary teeth and sequence of eruption of permanent teeth on malocclusion. J. Dent. Child., 20:2, 1953. 44. Kunze!, W.: Auswirkungen Rariesvorbeugender massnamen: Auf inhalt und struktus der kinderstomatologischen betreuwung 3. Dtsch. Stomat., 21:937, 1971. 45. Leske, G. S., and Leske, M. C. V.: The pediatrician in community dental health. Pediatrics, 54:182, 1974. 46. Lewis, T. E.: Incidence of fractured anterior teeth as related to their protrusion. Angle Orthod., 29: 128.-1959. 47. Lindhe, J., Hamp, S. E., and Loe, H.: Experimental periodontitis in the beagle dog. J. Periodont. Res., 8:1, 1973. 48. Loe, H.: Epidemiology of periodontal disease. Odont. T., 71:479, 1963. 49. Loe, H., Theilade, E., and Borglum, J. S.: Experimental gingivitis in man. J. Periodontal., 36:177, 1965. 50. McHugh, W. D.: Dentistry and the Community. Br. Dent. J., 121:428, 1966. 51. Nanda, R. S., Khan, I., and Anand, R.: Effect of oral habits on the occlusion in preschool children. J. Dent. Child., 39:449, 1972. 52. National Center for Health Statistics: Age patterns in medical care, illness, and disability -U.S. 1968-69, Vital and Health Statistics, Series 10, No. 70, DHEW Pub. No. (HSM) 72-1026, Washington, D.C., Government Printing Office, 1972. 53. National Center for Health Statistics: An assessment of the occlusion of teeth of youths 12-17 years. Vital and Health Statistics, Series 11, No. 162, DHEW Pub. No. (HRA) 77-1644, Washington, D.C., Government Printing Office, 1977. 54. Parfitt, G. J.: Distribution of caries in the primary dentition. Br. Dent. J., 99:423, 1955. 55. Pederson, J., Stensgaard, K., and Melsen, B.: Prevalence of malocclusion in relation to premature loss of primary teeth. Community Dent. Oral Epidemiol., 6:204, 1978. 56. Popovich, F., and Thompson, G. W.: Thumb and finger sucking: Its relation to malocclusion, Am. Jour. Orthod., 63:148, 1973. 57. Poulsen, S., and Moller, I. J.: The prevalence of dental caries, plaque and gingivitis in 3-year old Danish children. Scand. J. Dent. Res., 80:94, 1972. 58. Psychosocial aspects of craniofacial disfigurement. A "state of the art" assessment conducted by the Craniofacial Anomalies Program Branch, The National Institute of Dental Research. Am. Jour. Orthod., 76:410, 1979. 59. Ravn, J. J.: Dental injuries in Copenhagen school children, school years 1967-1972. Community Dent. Oral Epidemiol., 2:231, 1974. 60. Ravn, J. J.: Sequelae of acute mechanical traumata in the primary dentition. J. Dent. Child., 35:281, 1968. 61. Ripa, L. W., Leske, G. S., Sposato, A. L., eta!.: Supervised weekly rinsing with a 2% neutral NAF rinsing solution: Results of a demonstration project after four school years. J. Am. Dent. Assoc., 102:482, 1981. 62. Rolling, S.: Orthodontic examination of 2301 Danish children aged 9-10 years in a community dental service. Community Dent. Oral Epidemiol., 6:146, 1978. 63. Russell, A. L.: Some epidemiological characteristics of periodontal disease in a series of urban populations. J. Periodontal., 28:286, 1957. 64. Samant, A., Malik, C. P., and Chabra, S. K., et a!.: Gingivitis and periodontal disease in pregnancy. J. Periodontal., 47:415, 1976. 65. Sheiham, A.: The prevalence and severity of periodontal disease in Surrey school children. Dental Practitioner and Dental Record, 19:232, 1969.
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66. Stenger, J. M., Lawson, E. A., Wright, J. M., et a!.: Mouthguards: protection against shock to head, neck, and teeth. J. Am. Dent. Assoc., 69:273, 1964. 67. Stephan, R. M.: Changes in hydrogen ion concentration on tooth surfaces and in carious lesions. J. Am. Dent. Assoc., 27:718, 1940. 68. Subtelney, J. D.: The significance of adenoid tissue in orthodontia. Angle Orthod., 24:59, 1954. 69. Subtelney, J. D.: Oral habit- studies in form, function, and therapy. Angle Orthod., 43:347, 1973. 70. Sutcliffe, P.: A longitudinal study of gingivitis and puberty. J. Periodont. Res., 7:2, 1972. 71. Volker, J. F., and Russell, D. L.: The epidemiology of dental caries. In Finn, S. B. (ed.): Clinical Pedodontics, 3rd ed. Philadelphia, W. B. Saunders Company, 1973. 72. Weiss, R. L., and Tritharty, A. H.: Between meal eating habits and dental caries experience in preschool children. Am. J. Public Health, 50:1097, 1960. 73. Winter, G. B., Hamilton, M. C., and James, P. M.: Role of the comforter as an etiologic agent in rampant caries of the deciduous dentition. Arch. Dis. Child., 41:207, 1966. Department of Pediatrics 6345 Tanar Drive Columbia, Maryland 21045
Children's Dental Health: Overview for the Physician Robert E. Miller, M.D., M.S. (Hyg.), * and David I. Rosenstein, D.M.D., M.P.H. f
Dental problems are very common and affect people of all ages. The physical and emotional discomfort, economic loss, and inconvenience can be significant. Primary care physicians providing health care for children can prevent morbidity resulting from dental problems. This article will discuss the preventive role of the physician after presenting an overview of the prevalence, etiology, morbidity, and preventive measures for the most common pediatric dental problems seen by the primary care physician: caries, periodontal disease, malocclusion, and dental trauma.
CARIES Tooth decay is the most common dental problem found in children. In fact, it is the most common health problem found in children. Children of all ages and social classes frequently present with caries. In a fluoride-deficient area, Hennon and Stookey found that 8.3 per cent of 18- to 23-month-old children had dental caries and that the prevalence increased to 57.2 per cent by 36 to 39 months. 30 Results of the Ten State Nutrition Survey show that tooth decay becomes more prevalent with increasing age. The average number of carious teeth for children five and six years of age were 3.7 arid 5.1 respectively. 12 A Public Health Survey in the late 1960's demonstrated an increasing decayed, missing, and filled (DMF) teeth ratio through the teenage years which leveled out in early adulthood. 39 An Indiana study found that less than 4 per cent of a group of high school students were free of dental decay and that there was a mean of two to three new carious lesions per student per year. 15 The National Center for Health Statistics reported an average of 1.1 missing teeth due to caries in 17-year-old adolescents. 39 The data from these studies clearly show that children of all ages visiting the physician will have experienced dental decay, and some will have suffered tooth loss. *Director of Pediatric Outpatient Services, Assistant Professor of Pediatrics, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland f Professor and Chairman, Department of Public Health Dentistry, University of Oregon Health Sciences Center, Portland, Oregon
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Dental decay is caused by the acid products from bacteria in plaque when refined sugars, especially sucrose, act as substrates. The more frequent or prolonged the direct contact of sugar with teeth, the greater the incidence of carious lesions. 26 • 72 This is believed to be due to a more frequent drop in the pH of bacterial plaque, allowing acid dissolution of teeth by bacteria. 67 A classic longitudinal study over a five-year period revealed that Swedish children consuming "sticky" sugars in candies such as caramel and toffee had a higher incidence of caries than children eating foods with less toothadhering sugars. 26 "Nursing bottle caries" is caused by repeated pooling of sweetened liquids or acidic foods around the primary teeth of preschool children when using the nursing bottle for extended periods. 23 Case reports have implicated milk, 18 • 38 sweetened juices, 35 pacifiers dipped in sugary substances, 73 and liquid medications. 19 Data for the latter are not as convincing as for the others. Development and progression of caries depend on location of the lesion, age, diet, and fluoride intake. At age two years, 6 per cent of caries are found in the molar occlusive surfaces, 25 per cent are located in the proximal smfaces of incisors, and 2 per cent are found in the proximal molar surfaces. With increasing age and changing patterns of tooth eruption, approximately 50, 10, and 30 per cent of carious lesions are found in the molar occlusive, incisor proximal, and molar proximal surfaces respectively. 54 The caries attack pattern is similar for the pennanent dentition. In children six to 12 years of age, the majority of carious lesions are found in the permanent six-year molars and least commonly in the maxillary permanent central and lateral incisors. The percentage of lesions in the incisors increases, while that of the molars decreases with advancing age. At age 8, approximately 1 per cent of incisors are carious, as compared with 10 and 15 per cent at ages 11 and 12 respectively. 42 As with the primary dentition, occlusive caries are more prevalent than the proximal type. At age 12, about 50, 30, and 20 per cent of caries involving permanent tooth surfaces are occlusive, proximal, and buccal respectively. 71 Grondahl reported that caries progressed more slowly in teenagers. Over a three-year period, only 10 per cent of previously normal tooth surfaces had developed caries that were confined to the superficial enamel.2 5 Fluoridation of community water is the most effective, safe, convenient, and economical method of preventing caries. The ingestion of the appropriate amount of fluoride in drinking water during the period of tooth calcification will result in a reduction of caries of 50 to 70 per cent. 9 The classic 10-year study by Ast comparing the incidence of carious lesions in children living in a fluoridated area and in a fluoride-deficient area in upstate New York showed that children in the fluoridated area had 60 per cent fewer carious lesions than those in the fluoride-deficient area. Reduction in caries was correlated with exposure time to 1 ppm of fluoride in the water. Children ingesting fluoride beginning in the immediate newborn period developed fewer carious lesions than those starting fluoride intake later. In addition, systemic fluoride has been shown to be effective in preventing lesions on the proximal tooth surfaces, which are the most difficult and costly to treat. 2 The effects of fluoride in preventing dental caries were demonstrated in a Dutch study. The initiation and progression of caries were shown to be slower in a group of
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children consuming adequate amounts of fluoride. In addition, the results suggested that there was some reversal of existing lesions. 44 Unfortunately, there are approximately 114 million people in the United States who do not reside in areas with adequate fluoridation of water supplies. 16 Fluoride tablets, 5 school water fluoridation, 32 fluoride mouthrinse, 61 or topically applied fluoride 32 should be implemented in areas where the water is fluoride-deficient as an alternative to fluoridation of community water. These alternative methods are more difficult to accomplish and are more expensive than fluoridation of community water; they result in caries reduction of approximately 20 to 60 per cent.
PERIODONTAL DISEASE
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Many studies have confirmed the high prevalence of gingivitis in children.48· 57 By age three, most Scandinavian children have gingivitis. 5 7 Depending upon the criteria used for diagnosis, from 0.06 to 44 per cent of teenagers have more serious periodontitis. 7 • 14 Using the Periodontal Index, the National Center for Health Statistics reported that 38.7 per cent of children 6 to 11 years old have periodontal disease. Most of the children had only mild gingivitis. Periodontal pockets, a sign of chronic disease and a more serious problem than gingivitis, were found in only 0.8 per cent of the children. 40 Other studies show that moderate to severe periodontal disease is uncommon in the pediatric patient. 5°· 63 There is a definite relationship between gingivitis and bacterial plaque at the gingival margin. In a study now regarded as a classic, Loe stopped all methods of oral hygiene. This allowed plaque to accumulate, causing gingivitis within several days. 49 In another study, Axelsson and Lindhe compared a group of children who had their teeth professionally cleaned every two weeks with a control group. After one year, they reported almost total disappearance of gingivitis in the experimental group but not in the control group. 3 These two studies demonstrate the importance of plaque in the etiology of gingivitis and the importance of oral hygiene in preventing both plaque accumulation and gingivitis. Limited data suggest that gingivitis in childhood may progress to periodontitis with possible tooth loss in adulthood. 47 • 65 However, there is also evidence to suggest that childhood gingivitis and adult periodontitis may not represent a continuum. Physiologic changes during puberty may cause a temporary exaggerated response to the existing level of inflammation from dental plaque, which may result in an apparent increase in prevalence and severity of gingivitis during this period. In a longitudinal study of gingivitis in adolescents 11 to 17 years of age, Sutcliffe reported that gingivitis tended to peak and then decline during a six-year period and that peak periods of gingivitis did not correlate significantly with peak periods of poor oral hygiene. 70 Additional evidence for an exaggerated inflammatory response of the gingival tissues to physiologic factors was demonstrated in a longitudinal study by Hugoson, who showed that increases in prevalence and severity of gingivitis in pregnancy were related to simultaneous changes in female sex hormones. 34 Samant and colleagues demonstrated that there was a significant
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increase in the severity of gingivitis during pregnancy and that gingival changes showed a greater correlation with the calculus and the debris index in the pregnant group as compared with the control group. 64 Although far from conclusive, these studies suggest that there may be a reversible inflammatory gingival tissue response to bacterial plaque during specific stages of life.
MALOCCLUSION Studies documenting the prevalence of malocclusion and the need for orthodontic treatment in children vary depending upon diagnostic criteria. American and European literature report the prevalence of malocclusion to be between 60 and 78 per cent in children aged six to 12 years. 27 • 62 The National Center for Health Statistics reported that in a study sample of American children aged six to nine, 75 per cent had malocclusion: 39 per cent had minor manifestations, 22 per cent could be treated electively, 8.7 per cent needed treatment sooner, and 5.5 per cent required urgent treatment. 41 In a later study, the National Center for Health Statistics found that 16 per cent of adults had severe malocclusion. 53 Such variables as premature loss of primary teeth, 43 • 55 thumb-sucking and/or finger-sucking, 5 1 • 56 • 69 tongue thrusting, 69 ethnic group, 6 and hypertrophied tonsils and/or adenoids, 68 have been thought to produce malocclusion. Convincing data exist for the first two variables. Significant deviation in the anterior dental arch with forward-protruding incisors, especially maxillary incisors (overjet type), has been demonstrated in children with persistent thumb-sucking habits as compared with controls.s'· 56 Popovich studied children with thrumb-sucking habits longitudinally from age three to 12 and found that the effects of thumb-sucking on malocclusion were transient if the habit was stopped before six years of age. All children continuing to suck their thumbs after age six had abnormal occlusion. 56 Studies by Kronfeld 43 and by Pederson and colleagues 55 show that premature loss of primary teeth can result in malocclusion owing to drifting of adjacent teeth with accompanying space loss. The presence of malocclusion has been said to have an adverse effect on a child's self-esteem, adjustment, and body image and may evoke ridicule and teasing from other children. 24 • 58 However, poor orofacial appearance is a subjective phenomenon and attitudes and feelings about such a disorder may vary among individuals. Howitt et al. examined the relationship between the presence of malocclusion and self-satisfaction with occlusion and found that dissatisfaction with teeth increased sharply in subjects with poorer orthodontic conditions. However, the investigators found that one third of those dissatisfied with their dentition had reasonably esthetic dentitions. 33 Baldwin and Barnes investigated the motivation for seeking orthodontic treatment. The dentofacial deformity was the primary motivating factor in less than 5 per cent of the families. Such motives as the resolution of family problems and status-seeking were frequent. When the children were asked why they came to the orthodontist, one half responded that their mothers and two thirds responded that one or both parents were the main reason for obtaining treatment. 4 The results of these studies reveal the importance of assessing
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each child and family carefully for possible psychological and social effects of malocclusion and for the reasons for seeking treatment.
DENTAL TRAUMA A fourth common problem seen in children is traumatic injury to the dentition. A number of studies have demonstrated that the prevalence of injured teeth may be 25 to 30 per cent by age 12.1. 20 Thirty per cent of a group of black, inner-city children aged three to six years attending a Head Start Program had traumatized primary incisors. The frequency of injury in this study was the same for males and females. The maxillary incisors were involved in 74 per cent of injured teeth. The peak age of injury was between four and five years. 20 Jarvinen reported the frequency of injury to permanent incisors to be 19.8 per cent, with a boy to girl ratio of 1.7 to 1, with the greatest frequency of injury occurring at nine to 11 years. As with injuries to primary teeth, the maxillary permanent incisors were most frequently injured. 36 The causes of dental trauma in a study of children six to 16 years were collision and bumps in 37 per cent, fighting in 8 per cent, sports participation in 6 per cent, accidents in 6 per cent, and unknown in 4 per cent. There were no significant differences in causes of dental injuries between sexes. 59 A causal relationship between the frequency and severity of injuries to permanent anterior teeth and malocclusion of the overjet variety has been reportedY· 37 • 46 In a group of Finnish children seven to 16 years, Jarvinen found the frequency of injuries to maxillary permanent incisors to be 14.2 per cent in children with no oveljet, 28.4 per cent in children with mild to moderate oveljet, and 38.6 per cent in children with severe oveijetP The frequencies of types of injury from trauma in a study of children ranging in age from nine months to six years were intrusion in 35 per cent, loosening in 25 per cent, exarticulation in 19 per cent, and luxation in 15 per cent. Fractures of the crown and the root accounted for only 3 per cent and 2 per cent respectively. It was significant that exarticulation almost always resulted in damage to the corresponding permanent tooth. Intruded primary teeth usually reerupted within six months, but they often interfered with the eruption of succeeding permanent teeth. 60 Andreasen reported that luxation was the most common injury to the primary dentition and uncomplicated fractures were the most common injury to the permanent dentition. 1 Injury to permanent teeth can result in a less attractive physical appearance and the need for restorative care. The use of mouth and face protectors, especially in sports such as football, hockey, and boxing, has greatly reduced orofacial injuries. When mouth and face protectors were not used by football players, 50 per cent of all injuries were to the orofacial area. 28 The face guard protects against direct blows to the orofacial area and the mouth guard protects against blows under the chin and to the top of the head, which may cause acceleration of the head, deformation of bone, and increased intracranial pressure. 31 A five-year study at Notre Dame showed that the use of mouth protectors in football players significantly reduced the incidence of concussions and neck injuries. 66 After requiring the use of mouth protectors, the Amateur Hockey Association reported a decrease
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in dental injuries in 15- to 19-year-olds from 8.3 to 0 per cent over a three-year period.U Since 1962, many organizations involving children and young adults in competitive sports, such as the National Alliance and the National Collegiate Athletic Association, require the use of mouth protectors.
THE PHYSICIAN'S ROLE Because there is no associated mortality or obvious serious physical morbidity, physicians may overlook the importance of dental problems in children. From the material presented, it is clear that dental problems can result in organic and psychosocial morbidity. In discussing morbidity, however, the pain, discomfort, anxiety, restriction of activity, and economic loss from dental disease must be considered. In 1972, dental costs for American families totaled over five billion dollars. 45 According to a study by the United States government, there were 5.6 days ofbed disability and 14.6 days of restricted activity per 100 persons per year, and 50 million school hours were lost in 1968 owing to dental disease. 10 The physician's role is to maintain optimal dental health by preventing morbidity. The main activities for the physician in dealing with preventive dental health for children are assessment, education, prescription of fluoride, and referral. The content of these activities relate to caries, periodontal disease, malocclusion, and dental trauma. The assessment consists of a good dental history and physical examination. Information should be elicited regarding frequency and type of dietary sugar intake, type and amount of fluoride consumption, types and extent of oral hygiene practices, thumb- and/or finger-sucking habits, and the use of face and mouth protectors. The physician should inquire about the frequency of visits to the dentist. The content of the physical examination should be based on a knowledge of what the physician can realistically detect. In a study by Finn, children received oral examinations by a physician, nurse and then a dentist. The physician found 67.1 per cent, the nurse found 66.2 per cent, and the dentist found 2.7 per cent of these children to be free of caries. 21 The use of special instrumentation, lighting, and x-rays by the dentist increases the sensitivity of caries detection, especially interproximal lesions. The use of dental x-rays can increase the yield by 50 per cent. 8 If the physician does not discover caries on the physical examination, this does not mean that the child is free of caries. The physician cannot be expected to know the need for orthodontic treatment for all degrees of malocclusion, since there is often disagreement among orthodontists over this issue. 29 With these limitations in mind, the physical examination should include a thorough inspection of the teeth and gums for caries, traumatized or missing teeth, malocclusion, and signs of gingivitis, especially in teenagers. The typical distribution of caries involving maxillary incisors and/or molars and sparing the mandibular incisors in a preschool child is diagnostic of the "nursing bottle caries syndrome." After assessing the child, education should be provided to the patient and family based on the effectiveness of specific preventive measures. The need
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for fluoride should be explained, and fluoride should be prescribed if the content of fluoride in the family's drinking water is deficient. Separate prescriptions for fluoride should be dispensed to all children under 13 years of age residing in a fluoride-deficient area. Caution should be exercised in dispensing fluoride in combination form with vitamins, since fluoride intake inadvertently may be stopped when the vitamins are discontinued. Methods of oral hygiene should be explained to parents and children, particularly children over the age of 10. Parents and children should be advised about the appropriate type and frequency of refined sugar intake. If thumb-sucking persists beyond age four or five, psychological issues may need to be explored and pedodontic or orthodontic referral may be necessary. Inappropriate nursing bottle habits should be discouraged. The importance of face and mouth protectors for sports participation, especially football, hockey, wrestling, and boxing, should be explained. One of the most important preventive tools available to the primary care physician is referral to a dentist experienced in treating children. Unfortunately, approximately 30 per cent of all children under 1722 and 46.8 per cent 13 of all children under 12 in the United States have never been to a dentist. This situation is worse for children from poor families. Children from families with an income of over $15,000 per year are almost three times more likely to have visited a dentist in the past year as children from families with an income of less than $13,000 a year. 5 2 This is reflected in data showing children from low income homes to be more likely to have decayed and missing teeth rather than restored teeth. 39 Referral should be made for specific problems detected in the assessment as well as for routine dental care beginning at about age 18 months to two years. Children with specific medical and physical problems, such as congenital heart disease, diabetes, and blood dyscrasias, have special needs for dental care. Primary care physicians who are sensitive to these needs can work closely with the dentist to provide optimal dental care for these children.
CONCLUSION Dental problems are the most common health problems affecting children. The primary care physician providing health care for children can prevent the physical, psychosocial, and economic consequences of carie~, periodontitis, malocclusion, and trauma by appropriate assessment, education, and referral of children to the dentist. Referral to a dentist experienced in dealing with children and ensuring adequate fluoride intake in children residing in fluoride-deficient areas are two important preventive measures available to the physician.
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3. Axelsson, P., and Lindhe, J.: The effect of a preventive programme on dental plaque, gingivitis and caries in school children. Results after one and two years. J. Clin. Periodontal., 1:126, 1974. 4. Baldwin, D. C., and Barnes, M. L.: Psychosocial factors motivating orthodontic treatment. J. Dent. Res., 44:461, 1965. 5. Binder, K., Driscoll, W. S., and Shuzmannsky, G.: Caries-preventive fluoride tablet programs. Caries Res., 12:22, 1978. 6. Bjork, A., and Helm, S.: Need for orthodontic treatment as reflected in the prevalence of malocclusion in various ethnic groups. Acta Socio-Med. Scand., Suppl. 1:209, 1969. 7. Blankenstein, R., Murray, J. J., and Lind, 0. P.: Prevalence of chronic periodontitis in 13-15 year old children. J. Clin. Periodontal., 5:285, 1978. 8. Blayney, J., R., and Greco, J. F.: The Evanston dental caries study. IX. The value of roentgenological vs. clinical procedures for the recognition of early carious lesions on the proximal surfaces of teeth. J. Dent. Res., 31:341, 1952. 9. Blayney, J. R., and Hill, I. N.: Fluorine and dental caries. J. Am. Dent. Assoc., 74 {special issue): 233, 1967. 10. Carlos, J.P.: Prevention and oral health. NIH U.S. DHEW. Pub!. No. (NIH) 74-707, Washington, D.C., U.S. Government Printing Office, 1975. 11. Castaldi, C. L.: Mouth guards in contact sports. J. Conn. State Dent. Assoc., 48:233, 1974. 12. Center for Disease Control: Ten-State Nutrition Survey 1968-70, Vol. Ill. Clinical, Anthropometry, Dental DHEW Pub!. No. (HSM) 72-8173. Atlanta, Georgia, Center for Disease Control, 1972. 13. Craig, T. T., and Montague, J. L.: Family oral health survey. J. Am. Dent. Assoc., 92:326, 1976. 14. Davies, P. H. J., Downer, M. C., and Lennon, M.A.: Periodontal bone loss in English secondary school children. J. Clin. Periodontal., 5:278, 1978. 15. Dennison, D.: Dental Health Instruction Project: Final Report, Ball State University, Indiana, August, 1973. 16. Dunn eng, J. M.: Principles of Dental Public Health, 3rd ed. Howard Press, 1979. 17. Eichenbaum, I. W.: A correlation of traumatized anterior teeth to occlusion. J. Dent. Child., 30:229, 1963. 18. Fass, E. N.: Is bottle feeding of milk a factor in dental caries? J. Dent. Child., 29:245, 1962. 19. Feigal, R. J., Jensen, M. E., and Mensing, C. A.: Dental caries potential of liquid medications. Pediatrics, 68:416, 1981. 20. Ferguson, F. S., and Ripa, L. W.: Prevalence and type of traumatic injuries to the anterior teeth of preschool children. J. Pedod., 4:3, 1979. 21. Finn, S. B.: Prevalence of dental caries. In Survey of the Literature of Dental Caries, Publication No. 225, Washington, D. C. National Academy of Sciences-National Research Council, 1952, pp. 117-173. 22. Givens, J.D.: Current estimates from the Health Interview Survey. Vital and Health Statistics; Series 10, No. 130, DHEW Pub. No. (PHS) 80-1551, Washington, D.C., Government Printing Office, 1972. 23. Goose, D. H., and Gittus, E.: Infant feeding methods and dental caries. Public Health, 82:72, 1968. 24. Graber, L. W., and Lucher, G. W.: Dental esthetic self-evaluation and satisfaction. Am. J. Orthod., 77:163, 1980. 25. Grondahl, H. G., Hollander, L., and Malmcrona, E.: Dental caries and restorations in teenagers, II. Swed. Dent. J., 1:51, 1977. 26. Gustafsson, B. E., Quenset, C. E., Lanke, L. S., eta!.: Vipeholm dental caries study. Acta Odont. Scand., 11 :232, 1954. 27. Heikinhermo, K.: Need of orthodontic treatment in 7 year old Finnish children. Community Dent. Oral Epidemiol., 6:129, 1978. 28. Heintz, W. D.: Mouth protectors: A progress report. J. Am. Dent. Assoc., 77:632, 1968. 29. Helm, S., Kreiborg, S., and Barlebo, J., eta!.: Estimates of orthodontic treatment need in Danish school children. Community Dent. Oral Epidemiol., 3:136, 1975. 30. Hennon, D. K., Stookey, G. K., and Mihler, J. C.: Prevalence and distribution of dental caries in preschool children. J. Am. Dent. Assoc., 79:1405, 1969. 31. Hickey, J. C., Morris, A. L., and Carlson, L. D., eta!.: The relation of mouth protectors to cranial pressure and deformation. J. Am. Dent. Assoc., 74:735, 1967. 32. Horowitz, H. S.: A review of systemic and topical fluorides for the prevention of dental caries. Community Dent. Oral Epidemiol., 1:104, 1973. 33. Howitt, J. W., Stricher, G., and Henderson, L.: Eastman esthetic index. New York Dent. J., 33:215, 1967. 34. Hugoson, A.: Gingival inflammation and female sex hormones. J. Periodont. Res., Supplement 5, 1970.
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35. James, P. M. C., Parfitt, G. J., and Falkner, F.: A study of the etiology of labial caries of the deciduous incisor teeth in small children. Br. Dent. J., 103:37, 1957. 36. Jarvinen, S.: Fractured and avulsed permanent incisors in Finnish Children. Acta Odontol. Scand., 37:47, 1979. 37. Jarvinen, S.: Incisal oveljet and traumatic injuries to upper permanent incisors. Acta. Odontol. Scand., 36:359, 1978. 38. Jenkins, G. N., and Ferguson, D. B.: Milk and dental caries. Br. Dent. J., 120:472, 1966. 39. Kelly, J. E., and Harvey, C. R.: Decayed, Missing and Filled Teeth Among Youths 12-17 years, Vital and Health Statistics: Data from the National Health Survey, Series 11, No. 144, DHEW Pub!. No. (HRA) 75-1626, 1974. 40. Kelly, J. E., and Sanchez, M.: Periodontal disease and oral hygiene among children, Vital and Health Statistics, Series 11, DHEW Pub!. No. (HSM) 72-1060, No. 130, June, 1972. 41. Kelly, J. E., Sanchez, M., and Van Kirk, L. E.: An assessment of the occlusion of the teeth of children 6-9 years. Vital and Health Statistics, Series 11, No. 130, 1973. Washington, D.C., Government Printing Office. 42. Klein, H.: The Epidemiology of Dental Disease. Collected papers, 1937-47. Washington, D.C., Federal Security Agency, U.S. Public Health Service, 1948. 43. Kronfeld, S. M.: The effects of premature loss of primary teeth and sequence of eruption of permanent teeth on malocclusion. J. Dent. Child., 20:2, 1953. 44. Kunze!, W.: Auswirkungen Rariesvorbeugender massnamen: Auf inhalt und struktus der kinderstomatologischen betreuwung 3. Dtsch. Stomat., 21:937, 1971. 45. Leske, G. S., and Leske, M. C. V.: The pediatrician in community dental health. Pediatrics, 54:182, 1974. 46. Lewis, T. E.: Incidence of fractured anterior teeth as related to their protrusion. Angle Orthod., 29: 128.-1959. 47. Lindhe, J., Hamp, S. E., and Loe, H.: Experimental periodontitis in the beagle dog. J. Periodont. Res., 8:1, 1973. 48. Loe, H.: Epidemiology of periodontal disease. Odont. T., 71:479, 1963. 49. Loe, H., Theilade, E., and Borglum, J. S.: Experimental gingivitis in man. J. Periodontal., 36:177, 1965. 50. McHugh, W. D.: Dentistry and the Community. Br. Dent. J., 121:428, 1966. 51. Nanda, R. S., Khan, I., and Anand, R.: Effect of oral habits on the occlusion in preschool children. J. Dent. Child., 39:449, 1972. 52. National Center for Health Statistics: Age patterns in medical care, illness, and disability -U.S. 1968-69, Vital and Health Statistics, Series 10, No. 70, DHEW Pub. No. (HSM) 72-1026, Washington, D.C., Government Printing Office, 1972. 53. National Center for Health Statistics: An assessment of the occlusion of teeth of youths 12-17 years. Vital and Health Statistics, Series 11, No. 162, DHEW Pub. No. (HRA) 77-1644, Washington, D.C., Government Printing Office, 1977. 54. Parfitt, G. J.: Distribution of caries in the primary dentition. Br. Dent. J., 99:423, 1955. 55. Pederson, J., Stensgaard, K., and Melsen, B.: Prevalence of malocclusion in relation to premature loss of primary teeth. Community Dent. Oral Epidemiol., 6:204, 1978. 56. Popovich, F., and Thompson, G. W.: Thumb and finger sucking: Its relation to malocclusion, Am. Jour. Orthod., 63:148, 1973. 57. Poulsen, S., and Moller, I. J.: The prevalence of dental caries, plaque and gingivitis in 3-year old Danish children. Scand. J. Dent. Res., 80:94, 1972. 58. Psychosocial aspects of craniofacial disfigurement. A "state of the art" assessment conducted by the Craniofacial Anomalies Program Branch, The National Institute of Dental Research. Am. Jour. Orthod., 76:410, 1979. 59. Ravn, J. J.: Dental injuries in Copenhagen school children, school years 1967-1972. Community Dent. Oral Epidemiol., 2:231, 1974. 60. Ravn, J. J.: Sequelae of acute mechanical traumata in the primary dentition. J. Dent. Child., 35:281, 1968. 61. Ripa, L. W., Leske, G. S., Sposato, A. L., eta!.: Supervised weekly rinsing with a 2% neutral NAF rinsing solution: Results of a demonstration project after four school years. J. Am. Dent. Assoc., 102:482, 1981. 62. Rolling, S.: Orthodontic examination of 2301 Danish children aged 9-10 years in a community dental service. Community Dent. Oral Epidemiol., 6:146, 1978. 63. Russell, A. L.: Some epidemiological characteristics of periodontal disease in a series of urban populations. J. Periodontal., 28:286, 1957. 64. Samant, A., Malik, C. P., and Chabra, S. K., et a!.: Gingivitis and periodontal disease in pregnancy. J. Periodontal., 47:415, 1976. 65. Sheiham, A.: The prevalence and severity of periodontal disease in Surrey school children. Dental Practitioner and Dental Record, 19:232, 1969.
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66. Stenger, J. M., Lawson, E. A., Wright, J. M., et a!.: Mouthguards: protection against shock to head, neck, and teeth. J. Am. Dent. Assoc., 69:273, 1964. 67. Stephan, R. M.: Changes in hydrogen ion concentration on tooth surfaces and in carious lesions. J. Am. Dent. Assoc., 27:718, 1940. 68. Subtelney, J. D.: The significance of adenoid tissue in orthodontia. Angle Orthod., 24:59, 1954. 69. Subtelney, J. D.: Oral habit- studies in form, function, and therapy. Angle Orthod., 43:347, 1973. 70. Sutcliffe, P.: A longitudinal study of gingivitis and puberty. J. Periodont. Res., 7:2, 1972. 71. Volker, J. F., and Russell, D. L.: The epidemiology of dental caries. In Finn, S. B. (ed.): Clinical Pedodontics, 3rd ed. Philadelphia, W. B. Saunders Company, 1973. 72. Weiss, R. L., and Tritharty, A. H.: Between meal eating habits and dental caries experience in preschool children. Am. J. Public Health, 50:1097, 1960. 73. Winter, G. B., Hamilton, M. C., and James, P. M.: Role of the comforter as an etiologic agent in rampant caries of the deciduous dentition. Arch. Dis. Child., 41:207, 1966. Department of Pediatrics 6345 Tanar Drive Columbia, Maryland 21045