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Dental conditions in children: Its importance to the pediatrist
DEPARTMENT
OF
CHILDREN'S DENTISTRY DENTAL
CONDITIONS IN CHILDREN: TO THE PEDIATRIST* C.
B.
BRAY,
D.D.S.,
RIRMINGHAM,
ITS
IMPORTANCE
Am
A
S THE title of this paper indicates, it will deal with dental conditions found in children, which 1. believe will be of interest to you as pediatrists. We all know that in the past the dentistry of children has not been given the amount of serious consideration that it deserved. However, in recent years there has been an awakening to its importance, and it is now becoming one of the major specialties of dentistry. This has been brought about largely by the discovery of the effects of focal infection from the teeth and mouth on the body generally, and the realization that dental infection in childhood can be as common and as serious as in adult life, in its systemic as well as in its local manifestations. In a general discussion of this subject, it is well to remember that the teeth begin to form very early in embryonic life. For this reason, it is necessary in the prenatal care to begin the foundation for building good teeth. Diet of course is the earliest method of t.reatment and about all that can be done at this stage. However, it is important, and upon the obstetrician must fall the responsibility of giving proper advice as to diet. The eruption of the teeth is the next step, and in the majority of children the lower central incisors begin to erupt at about the age of six months. In some cases they erupt by the fourth month, and in others not until the eleventh to fourteenth month. The early or late eruption of the teeth in children otherwise normal does not imply any abnormality at all. It is merely an individual difference and is without bearing on the quality of the teeth or the general health. From the beginning of tooth eruption until its completion, which usually occurs at the age of three years, 1ittl.e attention is usually paid to the teeth, either by the dentist or the physician, except perhaps t.o advise the mother regarding thumb-sucking and lip-sucking, habits which will cause deformities if persisted in. However, from the age of three, preferably, and certainly from the age of four, the child should receive very careful dental attention. He should make frequent visits to the dentist, at least every three months, for an examination and prophylactic treatment. By so doing many painful and serious conditions can be prevented. *This paper read in Section on Pediatrics, Southern Medical Association, 26th annual meeting, New Orleans, La., November 18-20, 1931. This paper is published by courtesy of Dr. Bray and the Southern Medical Journal, Volume XXV, July, 1982, Number 7. 852
Dental Conditions
i,n C’hildrtw
4.-t:;
We must bear in mind that t,he deciduous teeth fill a very definite purpo~ and if possible, they should be retained and be kept in a healthy condirkn until they are replaced by the permanent, ones. In addition to imrnediat tX trouble, t.he future condition of the child’s mout.11 depends, to a large exrrni., upon the care given these teeth. It is well to recall that the deciduous trt4i have just as long roots as the permanent ones, and if t,hey a.re kept in a. healtll) state and free from cavities, the roots will gradually be absorbed as the prrruanrnt teeth are ready to erupt to replace them. H.owever, if they becomta ofiurascc1 and devitalized, normal physiologic absorption of the root does not occ~~r ant-1 any absorption that occurs is pathologic and due to infection. Dwing t.11t’ period of root absorption the deciduous teeth are not very resistant to &WQ-, and t,hcApermanent teeth, still, to an extent, in a formative state, arr not as strong and resistant to caries and infection as when their devel.opm& is cornplete. Such being the case! it is reasonable to believe that more care shorM be given the mouth and teeth at this period of life than at any other. I-iowc:~c~r~ in perhaps the majority of cases the reverse is true? and no serious t,hought is directed to the teeth by the dentist, or the physician, until the child complains of toot,hache. Then the dentist will find, instead of a reasonably normal atld healthy mouth, a mouth containing broken down and badly decayed t,eeth with large cavities full of unmasticated food, ayd oft.en dead and abscess&l teeth with fistu1a.s extending alon g the gum margins: or so-called gum-boils, with free pus draining continually into the mouth, some to be swallowed and sorn~~ taken up by t,he blood stream. Can we expect to find a normal, healthy c*llil(l under such conditions? The child cannot eat and will not try to do so because it hurts to chew; if food is taken, it, is not masticated, and is carried into fhtb stomach in a poorly digestible form. From blood stream absorption from :bc* infected foci around such teeth, we often find heart disease, pyelitis, rh
854
C. B. Bray
nature will make all repairs and adjustments and that the deciduous teeth will be lost in a short time anyway, so why bother to care for them. You have an excellent opportunity, in the course of your general physical examinations, to observe the condition of the mouth and teeth and to overcome this attitude on the part of many parents by appropriate advice and education ; and too, from your own standpoint in diagnosing disease: you will be neglecting the contributing cause of many ailments if you fail to take into consideration the oral condition of your patients. This is a very important step in the gen.. era1 physical examinat,ion of every child and the examination of the teeth should be painstaking and thorough. and where there is any doubt, x-ray examination should be made as well. In this regard, it is well to st.ate that an x-ray examination alone is not suflicient, and taken by itself may be misleading. When x-ray studies are made, a careful physical examination of the teeth and gums should be made and the findings of both examinations considered in reaching a diagnosis. Another subject to which I wish to refer briefly is Orthodontia. It is extremely important to recognize at an early age the exist,ence of dental irregularities that will require mechanical correction. It is very important that such conditions be corrected, not only from the esthetic standpoint but also because malocclusion is one gf the most f.requent causes of caries and pyorrhea. Teeth occluding improperly are subject to a continual trauma and soon the effects will become apparent in the teeth t,hemselves and in the peridental tissues. Children should be most carefully handled. Truthfulness by all means should be followed throughout. It is very unwise to be untruthful to your little patients or to misrepresent to them in any way anything you are doing or are going to do for them. Many appointments may be spent to good advantage by not doing anything for the child except to gain its confidence, and I feel that this is just as important to you as medical men as it is in dentistry. In conclusion, I wish to express my appreciation of the privilege of meeting with your Society, and I again wish to urge upon you the importance of dental conditions in children. The prophylaxis and treatment of the conditions of the teeth themselves are of course largely problems for the dentist. However, the proper supervision of the general health and the advice to parents which causes the child to be brought to the dentist are subjects in the sphere of the pediatrist, and it is from this standpoint especially that I ask your cooperat,ion. DISCUS$ION Dr. L. T. [email protected] more of us do not know the specialty. There are three causes of and feeble-mindedness. Many The next question is whether the teeth. Those of, you who dreamer and an idealist. But does influence teeth after the
of us neglect language of
the teeth dentistry.
and mouths of our patients, and still I think child dentistry should be a
failure of eruption of teeth; familial tendencies, malnutrition, times we can tell which is the cause, but frequently we cannot. food or hygiene is more important in preventing decay of heard Dr. Mellanby a year ago may feel he is somewhat of a he showed us irrefutable evidence that the state of nutrition permanent ones are erupted.
tootlr is citht,r good crl~~ll~l! The pediatrician should have this idea, that a temporary The dentist tod:iT Fho thinks in t<‘rrl~~ II! to be saved or bad enough to be taken out. pediatrics feels that way about it. Of course, some drfeetx of owlusion may rwuli. izlit economic problem, and t,lwe u+!l iw .I thev can be corrected. This is, of COU~W, a great time, perhaps, when orthodontia will be less exprnsivc than it is todny. Also, thrarc i- :I ~Iuestion a~ to how far tooth infections are responsible for some of the conditions 1 jr. Ilr;i: Orthodonti3. which 7 +t~n mc~ntiomd. That they do cnuse trouble thcrc can he no doubt. by th(l pedi3tri~~~:o~ sitltlr one of thr most important things in child lif<>, is !+tbldom stressed I Hope the d:ry will conrc~ when UP th:rl’ B ml almost never by the genernl practitioner. ICJIOIV how to prevent malocclusion of the teeth rat,hcr than 110~ to correct it. \vsJ Knin wt> slillltltl that fnultp habits of chewing and faulty h:tbits of swallowing cause m:hcc~lusion. tnkc these children to a man versed in orthodontia. Dr. D. Lesesrre Smib7a.-Wc who de31 with ehildrrn sh,ould not, forget that thr tc~th (‘:I n ~3uso us many symptoms 3s tonsils. The teeth are as frequently guilty of 3 train of srcondary symptoms, for instance, pyelitis, and the other diseases that go wit,li thr :rbsorpti~~~, of poisons. Enfortunatcly, dentists are seldom as willing to pull or extzaet disr~an4 tccatl~ I find it extremely hard somrtimcs to c:onvim~c~ as the thro:lt men are to take out tonsils. Frequently thrl c~hildren come f:ec>nt tltc dentist that it is the thing to estrart those teeth. the dent,ist to me for some trouble and I have to send them bxrk oithcr io thc~ sam(* tlr~nt14 or to another for the extraction of diseased teeth. Dr. A. A. Ilfczl&r.-Many yosrs ago the late Dr. .r. RsossSngdcr read il p3pm br’?rlrt the Section on Disrases of Children of the American Medical Association cm t,hr irnportnm~: of attention to the ttmporarp teeth when considering diseased conditions in clrildrc~rt. lie was *ne of the first in this country to insist t,hat teeth as well as tonsils shnnld wwi8 c’ It is largely duel to such pap(*rs a* the ill,,’ consideration in the practice of pediatrics. rrfcrrrd to that we have Dr. Bray on our program toda)-. I have always felt that the age at which dentition occurs is an individual charaolcriat ic and seldom bears any relationship to rirkcts. The rspericnce of tllo essayist apparently apws with this opinion. Dr. 80~ E. de la Hotlssaye.--We think too little nbout the eruption of tcetlr ant? t.IwiI care in pediatric practice today. Old practitioners and the majoritp of lay p~plt~ nttributc~ many ailments to teething. I am convinced that during dentition the gre3lcr nunrhr~r 11t bdbies seen by me have a lowered resist:mce to infec’tion. I have used cod liver oil and viosternl in large amounts, but still theye lrarra n
OF
CHILDREN'S DENTISTRY DENTAL
CONDITIONS IN CHILDREN: TO THE PEDIATRIST* C.
B.
BRAY,
D.D.S.,
RIRMINGHAM,
ITS
IMPORTANCE
Am
A
S THE title of this paper indicates, it will deal with dental conditions found in children, which 1. believe will be of interest to you as pediatrists. We all know that in the past the dentistry of children has not been given the amount of serious consideration that it deserved. However, in recent years there has been an awakening to its importance, and it is now becoming one of the major specialties of dentistry. This has been brought about largely by the discovery of the effects of focal infection from the teeth and mouth on the body generally, and the realization that dental infection in childhood can be as common and as serious as in adult life, in its systemic as well as in its local manifestations. In a general discussion of this subject, it is well to remember that the teeth begin to form very early in embryonic life. For this reason, it is necessary in the prenatal care to begin the foundation for building good teeth. Diet of course is the earliest method of t.reatment and about all that can be done at this stage. However, it is important, and upon the obstetrician must fall the responsibility of giving proper advice as to diet. The eruption of the teeth is the next step, and in the majority of children the lower central incisors begin to erupt at about the age of six months. In some cases they erupt by the fourth month, and in others not until the eleventh to fourteenth month. The early or late eruption of the teeth in children otherwise normal does not imply any abnormality at all. It is merely an individual difference and is without bearing on the quality of the teeth or the general health. From the beginning of tooth eruption until its completion, which usually occurs at the age of three years, 1ittl.e attention is usually paid to the teeth, either by the dentist or the physician, except perhaps t.o advise the mother regarding thumb-sucking and lip-sucking, habits which will cause deformities if persisted in. However, from the age of three, preferably, and certainly from the age of four, the child should receive very careful dental attention. He should make frequent visits to the dentist, at least every three months, for an examination and prophylactic treatment. By so doing many painful and serious conditions can be prevented. *This paper read in Section on Pediatrics, Southern Medical Association, 26th annual meeting, New Orleans, La., November 18-20, 1931. This paper is published by courtesy of Dr. Bray and the Southern Medical Journal, Volume XXV, July, 1982, Number 7. 852
Dental Conditions
i,n C’hildrtw
4.-t:;
We must bear in mind that t,he deciduous teeth fill a very definite purpo~ and if possible, they should be retained and be kept in a healthy condirkn until they are replaced by the permanent, ones. In addition to imrnediat tX trouble, t.he future condition of the child’s mout.11 depends, to a large exrrni., upon the care given these teeth. It is well to recall that the deciduous trt4i have just as long roots as the permanent ones, and if t,hey a.re kept in a. healtll) state and free from cavities, the roots will gradually be absorbed as the prrruanrnt teeth are ready to erupt to replace them. H.owever, if they becomta ofiurascc1 and devitalized, normal physiologic absorption of the root does not occ~~r ant-1 any absorption that occurs is pathologic and due to infection. Dwing t.11t’ period of root absorption the deciduous teeth are not very resistant to &WQ-, and t,hcApermanent teeth, still, to an extent, in a formative state, arr not as strong and resistant to caries and infection as when their devel.opm& is cornplete. Such being the case! it is reasonable to believe that more care shorM be given the mouth and teeth at this period of life than at any other. I-iowc:~c~r~ in perhaps the majority of cases the reverse is true? and no serious t,hought is directed to the teeth by the dentist, or the physician, until the child complains of toot,hache. Then the dentist will find, instead of a reasonably normal atld healthy mouth, a mouth containing broken down and badly decayed t,eeth with large cavities full of unmasticated food, ayd oft.en dead and abscess&l teeth with fistu1a.s extending alon g the gum margins: or so-called gum-boils, with free pus draining continually into the mouth, some to be swallowed and sorn~~ taken up by t,he blood stream. Can we expect to find a normal, healthy c*llil(l under such conditions? The child cannot eat and will not try to do so because it hurts to chew; if food is taken, it, is not masticated, and is carried into fhtb stomach in a poorly digestible form. From blood stream absorption from :bc* infected foci around such teeth, we often find heart disease, pyelitis, rh
854
C. B. Bray
nature will make all repairs and adjustments and that the deciduous teeth will be lost in a short time anyway, so why bother to care for them. You have an excellent opportunity, in the course of your general physical examinations, to observe the condition of the mouth and teeth and to overcome this attitude on the part of many parents by appropriate advice and education ; and too, from your own standpoint in diagnosing disease: you will be neglecting the contributing cause of many ailments if you fail to take into consideration the oral condition of your patients. This is a very important step in the gen.. era1 physical examinat,ion of every child and the examination of the teeth should be painstaking and thorough. and where there is any doubt, x-ray examination should be made as well. In this regard, it is well to st.ate that an x-ray examination alone is not suflicient, and taken by itself may be misleading. When x-ray studies are made, a careful physical examination of the teeth and gums should be made and the findings of both examinations considered in reaching a diagnosis. Another subject to which I wish to refer briefly is Orthodontia. It is extremely important to recognize at an early age the exist,ence of dental irregularities that will require mechanical correction. It is very important that such conditions be corrected, not only from the esthetic standpoint but also because malocclusion is one gf the most f.requent causes of caries and pyorrhea. Teeth occluding improperly are subject to a continual trauma and soon the effects will become apparent in the teeth t,hemselves and in the peridental tissues. Children should be most carefully handled. Truthfulness by all means should be followed throughout. It is very unwise to be untruthful to your little patients or to misrepresent to them in any way anything you are doing or are going to do for them. Many appointments may be spent to good advantage by not doing anything for the child except to gain its confidence, and I feel that this is just as important to you as medical men as it is in dentistry. In conclusion, I wish to express my appreciation of the privilege of meeting with your Society, and I again wish to urge upon you the importance of dental conditions in children. The prophylaxis and treatment of the conditions of the teeth themselves are of course largely problems for the dentist. However, the proper supervision of the general health and the advice to parents which causes the child to be brought to the dentist are subjects in the sphere of the pediatrist, and it is from this standpoint especially that I ask your cooperat,ion. DISCUS$ION Dr. L. T. [email protected] more of us do not know the specialty. There are three causes of and feeble-mindedness. Many The next question is whether the teeth. Those of, you who dreamer and an idealist. But does influence teeth after the
of us neglect language of
the teeth dentistry.
and mouths of our patients, and still I think child dentistry should be a
failure of eruption of teeth; familial tendencies, malnutrition, times we can tell which is the cause, but frequently we cannot. food or hygiene is more important in preventing decay of heard Dr. Mellanby a year ago may feel he is somewhat of a he showed us irrefutable evidence that the state of nutrition permanent ones are erupted.
tootlr is citht,r good crl~~ll~l! The pediatrician should have this idea, that a temporary The dentist tod:iT Fho thinks in t<‘rrl~~ II! to be saved or bad enough to be taken out. pediatrics feels that way about it. Of course, some drfeetx of owlusion may rwuli. izlit economic problem, and t,lwe u+!l iw .I thev can be corrected. This is, of COU~W, a great time, perhaps, when orthodontia will be less exprnsivc than it is todny. Also, thrarc i- :I ~Iuestion a~ to how far tooth infections are responsible for some of the conditions 1 jr. Ilr;i: Orthodonti3. which 7 +t~n mc~ntiomd. That they do cnuse trouble thcrc can he no doubt. by th(l pedi3tri~~~:o~ sitltlr one of thr most important things in child lif<>, is !+tbldom stressed I Hope the d:ry will conrc~ when UP th:rl’ B ml almost never by the genernl practitioner. ICJIOIV how to prevent malocclusion of the teeth rat,hcr than 110~ to correct it. \vsJ Knin wt> slillltltl that fnultp habits of chewing and faulty h:tbits of swallowing cause m:hcc~lusion. tnkc these children to a man versed in orthodontia. Dr. D. Lesesrre Smib7a.-Wc who de31 with ehildrrn sh,ould not, forget that thr tc~th (‘:I n ~3uso us many symptoms 3s tonsils. The teeth are as frequently guilty of 3 train of srcondary symptoms, for instance, pyelitis, and the other diseases that go wit,li thr :rbsorpti~~~, of poisons. Enfortunatcly, dentists are seldom as willing to pull or extzaet disr~an4 tccatl~ I find it extremely hard somrtimcs to c:onvim~c~ as the thro:lt men are to take out tonsils. Frequently thrl c~hildren come f:ec>nt tltc dentist that it is the thing to estrart those teeth. the dent,ist to me for some trouble and I have to send them bxrk oithcr io thc~ sam(* tlr~nt14 or to another for the extraction of diseased teeth. Dr. A. A. Ilfczl&r.-Many yosrs ago the late Dr. .r. RsossSngdcr read il p3pm br’?rlrt the Section on Disrases of Children of the American Medical Association cm t,hr irnportnm~: of attention to the ttmporarp teeth when considering diseased conditions in clrildrc~rt. lie was *ne of the first in this country to insist t,hat teeth as well as tonsils shnnld wwi8 c’ It is largely duel to such pap(*rs a* the ill,,’ consideration in the practice of pediatrics. rrfcrrrd to that we have Dr. Bray on our program toda)-. I have always felt that the age at which dentition occurs is an individual charaolcriat ic and seldom bears any relationship to rirkcts. The rspericnce of tllo essayist apparently apws with this opinion. Dr. 80~ E. de la Hotlssaye.--We think too little nbout the eruption of tcetlr ant? t.IwiI care in pediatric practice today. Old practitioners and the majoritp of lay p~plt~ nttributc~ many ailments to teething. I am convinced that during dentition the gre3lcr nunrhr~r 11t bdbies seen by me have a lowered resist:mce to infec’tion. I have used cod liver oil and viosternl in large amounts, but still theye lrarra n