Considerations in the Dental Management of the Adolescent

Symposium on Oral Health

Considerations in the Dental Management of the Adolescent

PaulS. Casamassimo, D.D.S., M.S.* and Cosmo R. Castaldi, D.D.S., M.S.D. f

Pediatrics has experienced an increased interest in adolescent health care over the last decade. Pediatric dentistry has traditionally devoted more attention to the dental health needs of this pivotal age group and to the many and rapid changes in physical and psychological characteristics of the adolescent. Adolescence is described variably, according to chronologie, physical, and psychological parameters, but in this article it will mean ages 10 to 21 years. It is -also the time of life characterized by the biologic changes of puberty and the emotional and psychological changes associated with the development of independence, sexual identity, and career direction. Adolescents are somewhere between childhood and adulthood, with the appeal and problems of both ages and some special problems of their own. The changes of adolescence have an impact on the oral cavity directly through growth of oral structures and indirectly through the effects of behavior on oral health and pursuit of care-seeking. The mixed dentition, comprising primary and permanent teeth, becomes the complete adult dentition during adolescence. The child's face becomes that of the adult and the adolescent develops lasting behaviors in oral habits, oral hygiene, and dental-care seeking that will last a lifetime. Oral hard and soft tissues are also subjected to stresses of life brought on by the increased independence of this age group. Smoking, trauma, infection, and medication all may present challenges to the evolving adult oral cavity. This article describes the oral changes of adolescents, some behaviors and attitudes of the adolescent dental patient, oral manifestations of selected adolescent dental disease, and the pediatrician's role in identification and referral. *Associate Professor and Chief of Dentistry, John F. Kennedy Child Development Center, and School of Dentistry, University of Colorado Health Sciences Center, Denver, Colorado fChairman, Department of Pediatric Dentistry, University of Connecticut Health Center, Farmington, Connecticut

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ORAL CHANGES IN ADOLESCENCE The oral cavity of the eight- or nine-year-old child is vastly different from that of an 18-year-old person. Changes occur in dentition, facial form and size, soft tissue appearance, and osseous structures. The mixed dentition of the majority of nine-year-old children usually includes permanent teeth and primary teeth. By age 12 or 13, all primary teeth will have been replaced by the premolars and canines and all permanent teeth but the third molars or wisdom teeth will have erupted. The transitional period in the changing dentition is pivotal for development of proper occlusion or bite. Most of the changes in this critical period occur between the lateral incisors anteriorly and the first permanent molars posteriorly. Variations in eruption patterns make this period of change even more complicated. The sequence of eruption of premolars and canines is highly variable and often depends on both systemic and local factors. In just three or four years, 20 teeth may change position, either as the result of exfoliation or eruption. These rapid changes in tooth position make adolescence a period of risk for the development of orthodontic problems such as crowding or crossbites. These rapid changes can be accentuated by premature loss of teeth from dental decay or traumatic injury. Loss of a first permanent (six-year) molar during adolescence can have deleterious long-term effects on the normal position of the posterior teeth and on the ability of the young person to chew properly. In fact, loss of one first molar reduces chewing efficiency by 50 per cent. 27 Replacement of the lost tooth or orthodontic treatment to rearrange the position of the teeth and restore normal function should be done as soon as possible after a permanent tooth is lost. Figures lA and 1B illustrate the rapidity of tooth movement of a 12-year-old girl who lost a first permanent molar. Six months later, the adjacent second molar had drifted and fipped into a position of malfunction. The pediatrician's role is to identify emerging problems and to make prompt referral. Delayed eruption, premature loss of teeth from decay or trauma, asymmetry of eruption, abnormalities of tooth shape or position, or functional deviations of jaw position should alert the physician to investigate further and make necessary referrals. Facial growth is another major area of change during adolescence. Facial growth usually involves the lower two thirds of the face, including the cranial base, the maxillae, and the mandible. Facial growth is important in determining how the maxillary and mandibular teeth occlude. For. example: The mandible and maxillae grow at different rates and in different amounts. The teeth in each of these structures must relate both to the structure and to the opposing teeth. Rapid growth of one or both jaws can upset the equilibrium of teeth and jaws, as well as make correctional orthodontic therapy, which attempts to reestablish equilibrium, difficult. Lower facial growth in adolescence follows general body growth during this period and is closely correlated with growth expressed as standing height. 16 The upper face includes the cranial base and maxillae. Endochondral ossification in the cranial base can continue to age 20. 12 The maxilla, which grows anteriorly and inferiorly during adolescence, reaches adult size by about 16 years on the average. Another contribution to the increase in

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Figure 1. A, Molar area of 12-year-old child, one week after extraction of the first permanent molar as a result of untreated dental caries. B, Same child six months later; the adjacent second molar has erupted into a position of malfunction.

facial dimension is from alveolar hone growth associated with the eruption of permanent teeth. The mandible hegins to grow rapidly in conjunction with the general growth spurt of adolescence- 12 years for girls and 14 for boys, on the average- and continues until late adolescence. 26 Mandibular growth is often unpredictable in its rate and absolute amount. Just as adolescents seem to grow almost overnight, so often does the mandible. This unpredictable growth can create problems in orthodontic therapy, since teeth are difficult to move through the dense hone of the mandible, and slight changes in mandibular size can greatly alter tooth-jaw relationships. Perhaps the most

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predictable and consistent aspect of mandibular growth during adolescence is the tendency for the mandible to grow anteriorly and inferiorly, thus adding to the straightness of the adult facial profile. The oral cavity of the adolescent also looks different from that of the child (Fig. 2). The gingival tissue of the adolescent is more keratinized and less vascular; it does not appear as red as the tissue of the child. The normal gingival tissue of the permanent dentition also takes on a more stippled appearance. Stippling refers to the minute indentations on the gingiva due to the connective papillae from the lamina propria. In cases of gingival inflammation, edema erases stippling, giving the gingiva a deep red, smooth appearance.25

Figure 2. A, Primary dentition of a five-year-old boy showing teeth in occlusion, spacing of primary teeth, and lack of significant stippling of gingival tissues. B, Incomplete adult dentition of an 18-year-old boy showing lack of spacing, pointed interdental papillae, and prominent stippling of gingival tissues.

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Figure 3. A, Normal healthy gingival tissue. B, C, D-Variations in gingival inflammation ranging from generalized marginal gingivitis around the necks of teeth in B to a more severe inflammatory condition most noticeable in this case around the maxillary anteriors and lower central incisors in C, to a fibrotic hypertrophied condition in D. Figure continued on following page

Figures 3 A, B, C, and D describe the variation in gingival health in a normal adolescent population. It ranges from a healthy, pale pink, slightly stippled appearance (A) to a marginal gingivitis mostly confined to the maxillary incisors, to more advanced types that include inflammation around the upper and lower incisors and calculus formation (B, C, D). The gingival inflammation does not seem to affect the posterior teeth so severely, for reasons that are not understood. The normally aligned adult dentition is without spacing. The close proximation of permanent teeth creates pointed interdental projections or papillae. The primary dentition is commonly spaced and the interdental gingival tissue is flatter, easier to clean, and less likely to become inflamed.

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Figure 3 (Continued)

The alveolar bone supporting the teeth and underlying the gingiva also differs from that of the child. It loses some of its elasticity, has fewer trabeculations, and smaller marrow spaces. The bone of the adult dentition also is less vascularized and more calcified than that of the child. The denser, less elastic bone accounts partly for the tendency toward tooth fractures rather than avulsions in the adolescent who sustains oral trauma. These changes in bone may also influence the beginning of periodontal disease and its alveolar bone destruction in adolescence.

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DENTAL DISEASE IN ADOLESCENCE Caries Most authorities agree that dental caries increases during adolescence, although there is less agreement about the extent of the caries problem. 29 Constant snacking on refined carbohydrate foods is thought to be the reason. 22 But tooth decay rates have significantly declined in the United States, 23 Great Britain, and Scandinavia24 during the last decade, most likely because of the increased use of fluorides, whether by community fluoridation, fluoride rinse programs in the public schools, or the easy availability of fluoride dentrifices (Table 1). Figure 4 illustrates the decline in caries attack rate in the United States between 1973 and 1981. Such extensive data are not available internationally for the full range of adolescence, but the World Health Organization has compiled decay rates for 12-year-old children which show considerable variation, from a high of 10.7 DMF (Decayed; Missing; Filled) for French Polynesia to a low of 0.1 for Zambia. 31 An interesting aspect of the data is that dental caries increases through adolescence, pointing to adolescence as an active caries period. Traditionally, adolescence has been viewed as the peak caries period, with high DMF rates due to previously restored primary teeth and the new susceptible surfaces of recently erupted permanent teeth. The increasing caries rate in adolescence, as indicated by the number of decayed teeth alone, supports the concept. of adolescence as an active caries period. It is not surprising that only about 4 per cent of high school age children are caries-free. 13 Newly erupted teeth adding more susceptible surfaces to decay is probably only one explanation for the continual increase in caries. Diets high in carbohydrate, inattention to oral hygiene, and frequent snacking also may contribute to caries in adolescence. The pediatrician needs to be aware that adolescence is not a nonrisk period from a dental standpoint, and dental evaluation should be included in the physical examination. Heavy plaque accumulation on teeth, staining of grooves, frank cavitation, abscess formation, dental pain, and changes in tooth color may all be evidence of tooth decay. All of these signs should encourage the pediatrician to make a referral to a dentist.

Table 1. World-Wide Levels of Dental Caries in 12-Year-Old Children AREA

Africa North and South America Europe Eastern Mediterranean Southeast Asia Western Pacific

RANGE OF DMF

0.1- 3.4

2.7- 8.7 1.0- 9.9 0.2- 4.5 0.7- 3.0 0.5-10.7

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Dental Caries in U.S. Children Comparison of 1971-73 survey and 1979-80 survey Combined race, male and female 16

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Age Figure 4. Decline in dental caries in the United States in the last decade. The graph shows a reduction of six DMFS in 17-year-old children over the 10-year period. The acceleration in disease rate is evident in the 11 to 17 year age range in both surveys but is less pronounced in the 1979-80 survey.

Periodontal Disease Other major dental problems of man are the periodontal diseases. These are often manifested in adolescence. Gingivitis is a common finding, believed to be caused by the interaction of hormones and local factors such as plaque or calculus (Fig. 5). Periodontal disease is often apparent in adolescence. age 18, some adolescents may have already suffered irreversible alveolar bone loss. Vital and Health Statistics also shows signs of periodontal disease increasing in adolescence. The Periodontal Index, a clinical measure of periodontal disease, shows a marked and consistent increase from 12 to 17 years of age. 21 The reasons for the increase in periodontal disease are complex and poorly understood. Even in the case of adolescent gingivitis, hormonal changes alone do not account for the level of disease. Changes in bone, soft tissue response to inflammation, oral hygiene behavior, and hormonal levels may all probably play a role in periodontal disease in the teenager. The pediatrician needs to be aware that adolescent gingival health affects the future periodontal health of the adult. Heavy calculus and plaque accumulation, especially around the gingival tissues; reddened gingiva; bleeding

By

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Figure 5. Dentition of a 14year-old girl showing enlargement of the gingival tissues, especially around the maxillary central incisors and the mandibular central and lateral incisors.

during toothbrushing; and halitosis may signal periodontal disease in the teenager and should prompt referral to a dentist. Malocclusion and traumatic injuries are common in adolescence, and are covered in other articles in this symposium. Specific caries patterns and periodontal conditions will be covered later in this article.

KNOWLEDGE, ATTITUDES, AND BEHAVIORS The literature has numerous empirical statements about adolescent attitudes and knowledge, but few studies in these areas. One large study20 of predominantly white Midwestern teenagers revealed that about three out of four of these adolescents felt that tooth decay was a serious matter and nine out of 10 had a regular dentist. About eight out of 10 teenagers in the study felt that tooth decay was preventable and brushed daily. However, the study showed that knowledge of basic dental disease was lacking- few knew about periodontal disease and only about one out of 10 flossed daily. The dental care received by teenagers in the study correlated closely with parental income, although knowledge did not. A study of inner city black teenagers aged 12 to 15 years compared their perceptions of their own oral health with objective assessments by dentists. 4 The teenagers in this study had a fairly good perception of dental health, but a poorer perception of gingival health. In addition, those who perceived more personal oral problems tended to have been at a dentist less recently, suggesting that the adolescents did not associate care-seeking with perception of problems. In an evaluation of clinic-type care-seeking, Lambert and Freeman 17 found that teenagers who had been accustomed to receiving services in public clinics did not seek care from the private practice sector when clinic services were denied because of age. At least one large national survey supports the concept that regular dental visits are at their highest in adolescence and tend to taper off in early adulthood and thereafter. 15

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A common motivating factor toward dental health and dental care among teenagers has appeared to be self-concept and the importance of the teeth and oral cavity in the adolescent's perception of physical attractiveness. At least one recent study of adolescents confirms that the face, teeth, and mouth are closely related to self-concept. 18 If one can generalize from the above data, it appears that the adolescent knows about tooth decay and the importance of daily toothbrushing. Knowledge of periodontal disease and steps to prevent it appear less solid. Dental care-seeking may be more dependent upon parental influence and resources than upon the adolescent's own feelings about the extent of their dental problems or the importance they place on their teeth and mouth.

Anxiety and Dental Phobias Fear of the dentist can be a significant deterrent to seeking care. Lack of sufficient communication between dentist and patient, a perceived lack of control by the patient, and a lack of knowledge appear to be major aspects of dental fear. 1° Fortunately, these are problems that can be managed by professional attention to individual needs. Relaxation techniques and desensitization have been shown to be effective behavior techniques to manage anxiety in adolescent and adult patients. 6 When behavior techniques are not effective, dentists may use medication to reduce anxiety. Nitrous oxide-oxygen inhalation analgesia is effective in reducing anxiety without postoperative problems or drowsiness. Valium administered orally or intravenously can also be an effective method to reduce anxiety. The adolescent who expresses anxiety about dental care should be referred to a dentist who uses behavioral and/or pharmacologic techniques to allay anxiety. The pediatrician and the dentist should work together to get the anxious adolescent to accept dental care. A psychologist may become involved to help deal with deep-seated anxiety and fear in ongoing therapy.

Role of the Pediatrician The pediatrician's role then becomes one of educator, motivator, and facilitator. The adolescent may be aware of the need for regular oral hygiene, but may not be ready or able to make it a priority in his or her life. Another adolescent may be aware of their need for regular dental care, but not ready to seek dental care because of a continuing dependence on parents for financial and emotional support or because of an inability to communicate with the dentist about concerns related to teeth. Some teenagers never accept dental care or have never developed as a dental patient because of ignorance about dental health. The dentition illustrated in Figure 6 belongs to an abused 17-year-old boy. He has difficulty accepting dental care because of a host of emotional and psychological problems and is only gradually accepting dental treatment, despite its potential esthetic and palliative benefits.

PERIODONTAL CONDITIONS Eruption Gingivitis During tooth eruption, the gingiva around a tooth may become inflamed. The loosely attached gingival tissue of the erupting tooth may be traumatized

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Figure 6. Dentition of a 17year-old adolescent showing extensive decav between the maxillary incisors an'd large accumulation~ of dental plaque around the cervical areas of the maxillary and mandibular teeth.

during mastication and become inflamed. This tissue undergoes adaptations as the tooth continually erupts. Tht·se processes can be associated with inflammatory changes. Soreness of this inflamed tissue leading to reluctance to brush the area also may contribute to the progression of inflammation. When the tooth is fully erupted, the gingivitis is usually resolved. Occasionally, the tooth will reach final position, and the gingi\'al tissue will not recede, resulting in an asymmetric appearance. This is maiJJly an esthetic concern that can be treated with minor surgery. 2

Adolescent Gingivitis The altered hormonal state of adolescence has led some to describe the gingivitis seen in adolescence as puberty gingivitis (Fig. 7). Most authorities now believe that hormone titers and local irritants such as plaque or calculus

Figure7. Dentition ofa 19-yearold boy with generalized marginal gingivitis. Note the disappearance of stippling from the inflamed gingival tissnPs along the cervical areas of teeth. Stain from smoking can be seen as black lines on the posterior teeth.

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Figure 8. Mandibular anterior teeth in 18-year-old boy with acute necrotizing ulcerative gingivitis. Note the destruction of the interdental papillae and white pseudomembranous areas. (Courtesy of Dr. james Kimmelman.)

act together to create the gingivitis seen in adolescence. Studies suggest a true hormonal component, 30 but the fact that adequate self-hygiene and regular dental prophylaxis can prevent puberty gingivitis in most cases disputes a purely hormonal etiology. 1 Treatment usually consists of differential diagnosis to rule out other systemic etiology, a rigid home oral hygiene program, and removal of accumulations of calculus by a dental professional. Some cases are refractory to intervention, but most respond to treatment or resolve spontaneously late in teenage. If untreated, the gingival tissues can become fibrotic or enlarged, requiring surgery to regain normal contours.

Acute Necrotizing Ulcerative Gingivitis Acute necrotizing ulcerative gingivitis (ANUG) is an infection caused by a spirochete, Borrelia vincentii. Also called trench mouth or Vincent's infection, the condition appears to be stress-related and affects teenagers and young adults. The classic signs and symptoms are pain, foul odor, and characteristic destruction of the interdental papillae (Fig. 8). The crater-like interdental lesions are often covered by a pseudomembrane that can extend to the gingival margin around the teeth. Lymphadenopathy, malaise, and fever may also be present, but most often diagnosis is made from oral signs. The organisms responsible are normal oral microflora. The relationship of stress to the condition suggests a host resistance factor. Fatigue, overwork, and other forms of stress seem to combine with local factors such as poor hygiene and local tissue trauma. Treatment consists of professional debridement of local irritants and regular self-applied oral hygiene plus either penicillin or metronidazole. Referral to a dentist for treatment is important because of the need for careful tissue debridement and post-acute gingival surgery to repair interdental tissue destruction. Without treatment, the condition can be tenacious and lead to significant tissue damage and recurrence.

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Pericoronitis Pericoronitis refers to inflammation of the tissue flap overlying crowded or partially erupted teeth, most commonly the third molars. The mandibular third molars are the teeth most often affected. The disease process begins with improper positioning of the tooth, resulting in an overlying gingival tissue flap. Initial swelling of the flap comes from food packing or plaque accumulation. As the flap swells, the opposing tooth traumatizes it, and aggravates the already inflamed tissue. The process can be chronic or acute and is occasionally associated with acute necrotizing ulcerative gingivitis. In acute cases, the condition may include limited jaw movement due to pain, bad breath from inattention to oral hygiene, lymphadenopathy, and cellulitis. Treatment of acute pericoronitis involves local irrigation and antibiotics to reduce accompanying infection. Post-acute management may include removal of the tissue flap or extraction of the teeth or monitoring the area and allowing the teeth to erupt. Infection can extend to the neighboring areas of the neck and pharyngeal region. 11

Effects of Oral Contraceptives Oral birth control medication can create gingival conditions similar to puberty or pregnancy gingivitis. 8 The pill can aggravate either generalized or localized inflammation (Fig. 9). The condition responds to removal of local factors such as plaque and calculus and is believed to be caused by interaction of hormone and local irritants. If untreated, gingivitis may progress to periodontitis and irreversible bone destruction. The hypercoagulability induced by oral contraceptives leads to increased postextraction alveolar osteitis, or dry socket, most commonly associated with mandibular third molar extraction. 19 Timing extractions with lower levels of circulating estrogen in the pill cycle tends to minimize this postoperative complication. 5

Figure 9. Maxillary anterior teeth of a 17-year-old girl taking oral contraceptives. The interdental area of the maxillary teeth demonstrates enlargement suggestive of a "pregnane~, tumor" or «pregnancy granuloma.

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Figure 10. Hyperkeratotic area in the mandibular vestibule of a 20year-old who used chewing t~bacco regularly for several years. Note the tobacco stain of the central incisors and the gingival cleft defect associated with the habit.

Effects of Tobacco As smoking and tobacco chewing become more prevalent in the adolescent population, signs of thermal and chemical damage will increase. Cigarette smoking can lead to a hyperkeratosis that gives the buccal mucosa a whitened appearance. The condition is reversible when smoking is decreased or stopped. Classic nicotinic stomatitis of the hard palate is very rare in the adolescent. Tobacco chewing creates mucosal and gingival problems that can affect the teeth through their supporting periodontal structures. The tobacco is held in the vestibule, subjecting the tissue to prolonged irritation (Fig. 10). In most cases, the result is hyperkeratosis, which is reversible. Chronic use can lead to leukoplakia, verrucous carcinoma, 28 and involvement of the gingival tissues. Clefting of gingiva, causing exposure of the root surface and weakening of tooth support is also possible. Surgery may be needed to correct tissue damage.

Oral Manifestations of Venereal Disease With infectious venereal disease reaching epidemic proportions in the adolescent population, the pediatrician treating teenagers needs to be alert for oral signs of sexually transmitted conditions. It is beyond the scope of this chapter to describe the highly variable oral manifestations of infectious venereal disease, but Figure 11 illustrates some oral manifestations that may be encountered. Gonorrhea, syphilis, herpes progenitalis, and genital warts can all manifest as lesions in the oral cavity. 9

DENTAL AND OCCLUSAL PROBLEMS Rampant Caries Classic adolescent dental caries is usually a pattern of decay that affects mainly the pits and fissures of teeth and occasionally the interproximal

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Figure ll. A, Gonococcal glossitis. B, Venereal warts in adolescent engaging in repeated oral sex with same partner for several months. C, Chancre of the tongue. Figure continued on following page

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Figure 11 (Continued). D, Maculopapular rash of tongue in secondary syphilis. E, Type II herpetic lesion of tonsil. (Courtesy of Dr. Howard Needleman.)

surfaces of posterior teeth. Rampant caries is a much more severe pattern, occurring over a much shorter period of time and affecting both anterior and posterior teeth (Fig. 12). The destruction of teeth is rapid and severe and it is common to see posterior teeth decayed to the gingival margin, anterior teeth with large interproximal lesions, cavitation on facial surfaces with exposed yellowish dentin, and abscesses on the alveolar gingiva. The decayed tooth structure may be so soft that it can be peeled off, and fracturing of teeth is not unusual. Because of the rapid progression of decay and the irreversible nature of the destruction, immediate treatment is critical. Dental treatment of rampant caries often includes excavation of decay and placement of sedative temporary restorations, extraction of badly decayed teeth, and preventive measures

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Figure 12. Rampant dental caries in a 14-year-old girl. Note the extensive destruction of the maxillary incisors and the large interproximal caries of the mandibular anterior teeth. This patient had numerous teeth e1
including fluoride supplementation and diet modification. Long-term treatment often includes root canal therapy, restoration of teeth, and prosthetic replacement of teeth that have had to be extracted.

Anorexia N ervosa The teeth can be affected in anorexia nervosa. 3 The anorexic may have a high carbohydrate intake for energy or the physician may prescribe a high calorie diet for weight gain, both of which can increase susceptibility to dental caries. Periodontal disease from neglect is also a finding. The most serious complication is acid dissolution of teeth as a result of regurgitation of gastric contents. The destruction of enamel and dentin is called perimyolysis and results from exposure to the low pH fluid. Most often, the .lingual and occlusal surfaces are affected. Loss of enamel from the biting surfaces exposes the softer dentin, which is also eventually lost. The clinical appearance of perimyolysis suggests that the fillings are "growing" out of the teeth (Fig. 13A). Dissolution of lingual tooth structure tends to weaken the teeth, which can fracture, giving a ragged-edge appearance (Fig. 13, B and C). Cessation of regurgitation stops the destruction, but teeth often must be . restored with crowns to prevent further wearing away of dentin, fractures of weakened teeth, and to protect pulpal tissues. The anorexic with obvious dental pathosis or suspected regurgitation should be referred for evaluation and consideration of preventive therapy.

Third Molars Late adolescence is the time of eruption of the third molars or wisdom teeth. Controversy still exists about routine extraction of these teeth. The concept of anterior tooth crowding from pressure by third molars has been mainly dispelled, and a decision to extract is based most often on three criteria: function, existing pathosis, or potential pathosis. If the third molars are used in chewing and can fit into the dental arch, they should be kept. Occasionally, malposition and difficulty in cleaning will require extraction despite an adequate functional role. Existing pathosis -recurrent pericoroni-

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Figure 13. Amalgam restorations on the first and second molars appear to have rough margins and seem to have "grown" out of the teeth due to the loss of enamel around them. B, Fractured incisal or biting edges of anterior teeth in anorexic patient. C, Shows extensive loss of lingual enamel and dentin as evidenced by the amalgam that protmdes from the surface of the canine. (Courtesy of Dr. Don Kleier.)

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tis, tooth decay, periodontal problems, or cystic involvement- may suggest extraction. Third molars that are moderately to severely impacted- malposed, partially erupted, and partially or totally covered with bone- should be extracted to prevent future abscess or cyst formation. The longer the teeth are retained, the more difficult the extraction. The choice for extraction is an individual one made by the adolescent in consultation with the dentist. The pediatrician's role is early identification and referral for evaluation.

Myofascial Pain Dysfunction and Temporomandibular Joint Problems · Temporomandibular joint problems can occur in adolescence. Difficulties with jaw opening and joint pain occasionally have organic etiology such as trauma, arthritis, or malformation, but the most common etiology appears to be stress. Myofascial pain dysfunction syndrome is the term used to describe the psychophysiologic condition most often associated with temporomandibular pain. 14 Myofascial pain dysfunction is usually characterized by a chief complaint

Figure 14. 14-year-old girl with congenitally missing left maxillary incisor and peg-shaped right lateral incisor. The adjacent teeth have drifted into the space, resulting in a disfiguring appearance when she smiles.

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of unilateral ear pain that may radiate to the temporal, cervical, or mandibular angle region. The pain is usually a dull ache, often worse in the morning owing to night grinding of teeth. Bruxism or grinding is a frequent finding in myofascial pain dysfunction. Chewing may be painful and jaw movement limited owing to tenderness of muscles of mastication. The jaw may click upon opening owing to uncoordinated opening. In the absence of other clinical findings suggestive of organic basis to temporomandibular joint pain, the signs of pain, limited jaw movement, muscle tenderness, and temporomandibular joint clicking should suggest myofascial pain dysfunction. Treatment of myofascial pain dysfunction in the adolescent is by no. means definitive. It may include total heat applications for tenderness, medications for muscle relaxation and/or anxiety reduction and adjustment of the occlusion to eliminate bruxism and stabilize the bite. Some recommend jaw exercises to restore normal function. Diet may also be altered to minimize stress on the joint from chewing, and extreme movements such as yawning are discouraged. A major therapeutic approach is to provide counseling by the appropriate professional for management of stress.

CONGENITALLY MISSING TEETH Approximately one out of every fifty adolescents has at least one congenitally missing tooth, either a maxillary incisor or a premolar. Missing posterior teeth tend to complicate dental treatment. A missing maxillary incisor with malalignment (Fig. 14) can have a devastating effect on a young person from a peer group characteristically sensitive to appearance. 18

REFERENCES 1. Baer, P. N., and Benjamin, S. D.: Periodontal Disease in Children and Adolescents. Philadelphia, J. B. Lippincott Company, 1974. 2. Borden, S. M.: Periodontics. In Castaldi, C. R., and Brass, G. A. (eds.): Dentistry for the Adolescent. Philadelphia, W. B. Saunders Company, 1980. 3. Brady, W. F.: The anorexia nervosa syndrome. Oral Surg., 50:509, 1980. 4. Brunswick, A. F., and Nikias, M.: Dentists' ratings and adolescents' perceptions of oral health. J. Dent. Res., 54:836, 1975. 5. Catellani, J. E., Harvey, S., Erickson, S. H., eta!.: Effect of oral contraceptive cycle on dry socket (localized alveolar osteitis). J. Am. Dent. Assoc., 101:777, 1980. 6. Corah, N. L., Gale, E. N., Pace, L. F., eta!.: Relaxation and musical programming as means of reducing psychological stress during dental procedures. J. Am. Dent. Assoc., 103:232, 1981. 7. Decayed, missing and filled teeth among youths 12-17 years. Vital and Health Statistics: Data from the National Health Survey, Series 11, No. 144, 1974. 8. El Ashiry, G. M., Kafrawy, A. L., Nasir, M. F., eta!.: Effects of oral contraceptives on the gingiva. J. Periodontol., 42:273, 1971. 9. Fiumara, N.J.: Venereal diseases of the oral cavity. J. Oral Med., 31:36, 1976. 10. Gatchel, R. J.: Effectiveness of two procedures for reducing dental fear: Group-administered desensitization and group education and discussion. J. Am. Dent. Assoc., 101:634, 1980. 11. Glickman, 1.: Clinical Periodontology, Philadelphia, W. B. Saunders Company, 1964. 12. Graber, T. M.: Orthodontics, 2nd ed. Philadelphia, W. B. Saunders Company, 1969. 13. Greenberg, J. S.: An analysis of various teaching modes in dental health education. J. School Health, 47:26, 1977. 14. Guralnick, W., Kahan, L. B., and Merrill, R. G.: Temporomandibular-joint affiictions. N. Engl. J. Med., 299:123, 1978. 15. Health attitudes and behavior of youths 12-17 years: Demographic and Socioeconomic Factors. Vital and Health Statistics: Data from the National Health Survey, Series 11, No. 153, 1975.

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