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Teeth
TEETH HENRY M. WILBUR, D.D.S.
A large field of special interest to those who devote time to children concerns growth and development problems. There is no eJ
The eruption of a tooth represents the culmination of a series of developmental stages which began during the fourth or fifth week of embryonic life and will continue into young adulthood. It will not end until the third permanent molar emerges. Eruption usually begins by about six months of age with the emergence of four primary central incisors, two below and two above. After this there is a rest period of about four months, at which time the next crop of four teeth appears. This pattern of four teeth every four months is a h'wdy "rule-of-thumb." Thus: AT AGE
7 11 15 19 23
months months months months months
NUMBER OF TEETH ERUPTED
4 8 12 16 20
central incisors teeth teeth teeth teeth
It should be noted that after the first group, consisting of four primary central incisors, has erupted there is no specific designation of what comprises the succeeding groups. Frequently their order is central incisor, lateral incisor, primary first molar, cuspid and primary second molar. Almost always the central incisors are the first teeth 91
92
TEETH
to erupt, and usually the primary second molars are the last to erupt. Otherwise there is considerable variation. The lower teeth usually precede the corresponding upper teeth. Age for age, girls' teeth tend to precede boys' teeth in their eruption schedule. SYMPTOMS OF TEETHING
The occurrence of symptoms, including fever, loss of appetite, sleeplessness, increased salivation and drooling, gnawing, coughing and convulsions, during the time when the primary teeth are erupting has led to much controversy and speculation. The controversy rages over the relation, if any, between the eruption of teeth and such symptoms as these. Some investigators and authors have maintained that the difficulty a child may have while teething is a pathologic process and that it is the cause of the symptoms. Others maintain that the symptoms are only coincidental. Whatever the truth may be, the teething process is usually a rapid one, and any associated symptoms seem to subside once the tooth has erupted through the mucosa. Any symptoms still persisting after the tooth has erupted are presumably unrelated, and one should search elsewhere for their cause. The mucosa covering a tooth will occasionally be inflamed and irritated just before the emergence of a tooth. Lancing of this overlying mucous membrane is hazardous in that it may provide entry for infection. Furthermore, this procedure usually aggrzvates the problem it is supposed to cure. It does seem that an object which is hard and cold on which the infant may gnaw may be useful as a symptomatic measure. DENTITIO PRAECOX
Occasionally a child is born with a tooth or two already erupted. These teeth are usually paired and in the lower central incisor area. They may be normal primary centrals, precociously erupted, or they may be supernumerary teeth. If they are supernumerary, their texture and root formation are abnormal. If these precocious teeth interfere with the infant's nursing, they should be removed. They may lack root formation, making them easily loosened. In this case they should be extracted because of the danger of aspiration, if for no other reason. A careful x-ray examination should be made to differentiate between supernumerary teeth and normal teeth precociously erupted. If precociously erupted normal primary incisors are extracted, their absence will result in abnormal mandibular development. THUMB-SUCKING
A controversy which frequently arises whenever physicians and dentists discuss mutual problems is that of prolonged digital habits, especial~y thumb-sucking. ,Dentists, especially orthodontists and pedodoQtists, are upset because attempts have not been made to correct this habit before it has produced a dental malocclusion or malalignment. These
HENRY M. WILBUR
93
dental specialists, looking backward from the time of their first examination of such a malocclusion, say, "Why wasn't this thumb-sucking habit corrected before it produced this malocclusion?" The pediatrician or the family physician, to whom this complaint is often directed, often replies, "This sucking habit is innocuous, will be discontinued by the child as he grows older and need not be interfered with." It is true that an intense, active digital habit, practiced over a long enough time, can produce a severe upper anterior protrusion. This is often complicated by a constriction of the upper dental arch because of the inward pressure of the buccal musculature. The upper arch constriction and the posterior pressure of the thumb and hand on the mandible can result in an inhibition of the normal anterior positioning of the mandible. The total deformity can be extreme and difficult to correct. Certainly some earlier interference with this kind of habit should be undertaken. It now seems somewhat clearer that the attention of both physician and dentist should not be directed so much to the thumb-sucking habit, but to the thumb-sucking child. To be sure, so many infants have a habit of sucking the thumb or finger that it is often considered a part of normal development. Most children discontinue this digital habit some time during early childhood, often by the third birthday. Some children, however, continue the practice after this early age, maintaining it largely as a hand-occupation habit. It may be speculated that smoking by the adult is a remote reflection of this hand-occupation habit. Such a habit may consist in passive holding or resting of the digit in the mouth without much muscular activity of either the digit or the oral muscles. It seems that what the orthodontist and pedodontist are chiefly concerned with are those children who practice a digital habit intensely, agressively and passionately, for long periods at a time, and continue to do so even until their permanent incisors begin to erupt after the seventh birthday. Such a child is obviously immature emotionally and is a cause of concern to both physician and dentist. His habit is only a symptom. Once this philosophy of individualization is achieved, the approach to treatment may also be individualized. Child and family counseling had perhaps best be undertaken by the family physician in an effort to uncover emotional factors which might be responsible. The dentist may be ready to provide the child with a "habit reminder" appliance, an intraoral device intended to remind the child that the digit is back in its old haunts where it shouldn't be. Parenthetically, it is suspected that sometimes such a "brace" may be a sort of status symbol, but nevertheless very useful as a means of setting the child apart from his contemporaries. ACCIDENTS AND INJURIES
This subject is introduced because it is partly developmental and is frequently overlooked. Injuries to the teeth and their sequelae are
94
TEETH
developmental because they occur mainly at two age periods when motor coordination is being tested in a new and different way. Thus the infant, after a period of aimless movement of arms and legs, followed by a quadrupedal type of locomotion, apparently feels that he is built for bipedal primate locomotion and tries it out. During this experimental period there are many physical contacts with many immovable objects. When these contacts are made by way of the child's young primary incisors, a problem is created which is frequently overlooked or minimized by the examiner. Later on in a child's life there is another testing period when body contact games and sports are being tried out. This developmental period is also fraught with dental hazards, complicated by the kind of dentition development of the individual child. Thus, when a child's permanent incisor dentition development is characterized by a protrusion of these teeth, they frequently are the first point of contact with an object directed at the mouth. The injuries produced by these accidents differ because of the development of the child. The primary teeth, being supported in less well calcified alveolar bone, tend to be dislocated and displaced. The permanent teeth of the older child tend to be fractured. The treatment of injuries to primary incisors frequently consists in repositioning the displaced tooth (or teeth) into more or less normal position in the dental arch and securing it (or them) there for a few days until supporting bone matrix can be rebuilt. This splint may be easily constructed by the dentist from self-polymerizing methyl methacrylate resin which is then cemented over the teeth with medicated zinc oxide-eugenol. Even this rapid extemporaneous treatment is unnecessary if the accident has driven the primary incisor into the alveolar process. An incisor injured in this way will re-erupt and usually take its normal place in the dental arch. There is a remote sequela of a displacement injury tv a primary incisor. Its permanent successor may be disturbed in its follicle and develop in a distorted form, either of its crown or its root, depending upon the stage of development at the time of the accident. The treatment of injured permanent incisors is a technical dental problem and need not be discussed here. Suffice it to say that such treatment is divided into an emergency phase, an intermediate phase intended to tide the patient over the adolescent developmental period, and the final phase when the patient is a young adult. The important consideration is that an accidental injury needs dental consultation at once and that the dentist is best qualified to make the diagnosis of the extent of the injury and to institute appropriate treatment. With present knowledge it is no longer enough to say, "Nothing can be done until the patient is 18 years old." A final word can be included here about prevention of dental injuries to school children who are engaging in body-contact games such as football or basketball. Such a preventive program consists in equipping a football team or a basketball team with mouth guards similar to boxers' mouthpieces, but much less cumbersome. Newer
HENRY M. WILBUR
95
latex-like materials make such a streamlined appliance feasible, and its cost is modest. The cooperation of the local dental profession is necessary in order to provide a model of each player's teeth over which the latex material is processed to make an individual mouth guard. These guards protect the players from dental injuries and are easily and inexpensively fabricated. They are certainly worth the effort in prevention of injuries which are often difficult and painful to treat as well as disfiguring. SUMMARY
As in other fields devoted to the health care of children, dental practice also has problems peculiar to youngsters as contrasted to adults. These problems are related here, as elsewhere, to growth and include such matters as abnormalities in the eruption of teeth, malocclusion or malalignment due to thumb-sucking, and injuries during various stages of growth and development. Proper management and disposition of some of these dental problems depends upon an understanding of these relations. 129 K Broadway Louisville 2, Ky.
A large field of special interest to those who devote time to children concerns growth and development problems. There is no eJ
The eruption of a tooth represents the culmination of a series of developmental stages which began during the fourth or fifth week of embryonic life and will continue into young adulthood. It will not end until the third permanent molar emerges. Eruption usually begins by about six months of age with the emergence of four primary central incisors, two below and two above. After this there is a rest period of about four months, at which time the next crop of four teeth appears. This pattern of four teeth every four months is a h'wdy "rule-of-thumb." Thus: AT AGE
7 11 15 19 23
months months months months months
NUMBER OF TEETH ERUPTED
4 8 12 16 20
central incisors teeth teeth teeth teeth
It should be noted that after the first group, consisting of four primary central incisors, has erupted there is no specific designation of what comprises the succeeding groups. Frequently their order is central incisor, lateral incisor, primary first molar, cuspid and primary second molar. Almost always the central incisors are the first teeth 91
92
TEETH
to erupt, and usually the primary second molars are the last to erupt. Otherwise there is considerable variation. The lower teeth usually precede the corresponding upper teeth. Age for age, girls' teeth tend to precede boys' teeth in their eruption schedule. SYMPTOMS OF TEETHING
The occurrence of symptoms, including fever, loss of appetite, sleeplessness, increased salivation and drooling, gnawing, coughing and convulsions, during the time when the primary teeth are erupting has led to much controversy and speculation. The controversy rages over the relation, if any, between the eruption of teeth and such symptoms as these. Some investigators and authors have maintained that the difficulty a child may have while teething is a pathologic process and that it is the cause of the symptoms. Others maintain that the symptoms are only coincidental. Whatever the truth may be, the teething process is usually a rapid one, and any associated symptoms seem to subside once the tooth has erupted through the mucosa. Any symptoms still persisting after the tooth has erupted are presumably unrelated, and one should search elsewhere for their cause. The mucosa covering a tooth will occasionally be inflamed and irritated just before the emergence of a tooth. Lancing of this overlying mucous membrane is hazardous in that it may provide entry for infection. Furthermore, this procedure usually aggrzvates the problem it is supposed to cure. It does seem that an object which is hard and cold on which the infant may gnaw may be useful as a symptomatic measure. DENTITIO PRAECOX
Occasionally a child is born with a tooth or two already erupted. These teeth are usually paired and in the lower central incisor area. They may be normal primary centrals, precociously erupted, or they may be supernumerary teeth. If they are supernumerary, their texture and root formation are abnormal. If these precocious teeth interfere with the infant's nursing, they should be removed. They may lack root formation, making them easily loosened. In this case they should be extracted because of the danger of aspiration, if for no other reason. A careful x-ray examination should be made to differentiate between supernumerary teeth and normal teeth precociously erupted. If precociously erupted normal primary incisors are extracted, their absence will result in abnormal mandibular development. THUMB-SUCKING
A controversy which frequently arises whenever physicians and dentists discuss mutual problems is that of prolonged digital habits, especial~y thumb-sucking. ,Dentists, especially orthodontists and pedodoQtists, are upset because attempts have not been made to correct this habit before it has produced a dental malocclusion or malalignment. These
HENRY M. WILBUR
93
dental specialists, looking backward from the time of their first examination of such a malocclusion, say, "Why wasn't this thumb-sucking habit corrected before it produced this malocclusion?" The pediatrician or the family physician, to whom this complaint is often directed, often replies, "This sucking habit is innocuous, will be discontinued by the child as he grows older and need not be interfered with." It is true that an intense, active digital habit, practiced over a long enough time, can produce a severe upper anterior protrusion. This is often complicated by a constriction of the upper dental arch because of the inward pressure of the buccal musculature. The upper arch constriction and the posterior pressure of the thumb and hand on the mandible can result in an inhibition of the normal anterior positioning of the mandible. The total deformity can be extreme and difficult to correct. Certainly some earlier interference with this kind of habit should be undertaken. It now seems somewhat clearer that the attention of both physician and dentist should not be directed so much to the thumb-sucking habit, but to the thumb-sucking child. To be sure, so many infants have a habit of sucking the thumb or finger that it is often considered a part of normal development. Most children discontinue this digital habit some time during early childhood, often by the third birthday. Some children, however, continue the practice after this early age, maintaining it largely as a hand-occupation habit. It may be speculated that smoking by the adult is a remote reflection of this hand-occupation habit. Such a habit may consist in passive holding or resting of the digit in the mouth without much muscular activity of either the digit or the oral muscles. It seems that what the orthodontist and pedodontist are chiefly concerned with are those children who practice a digital habit intensely, agressively and passionately, for long periods at a time, and continue to do so even until their permanent incisors begin to erupt after the seventh birthday. Such a child is obviously immature emotionally and is a cause of concern to both physician and dentist. His habit is only a symptom. Once this philosophy of individualization is achieved, the approach to treatment may also be individualized. Child and family counseling had perhaps best be undertaken by the family physician in an effort to uncover emotional factors which might be responsible. The dentist may be ready to provide the child with a "habit reminder" appliance, an intraoral device intended to remind the child that the digit is back in its old haunts where it shouldn't be. Parenthetically, it is suspected that sometimes such a "brace" may be a sort of status symbol, but nevertheless very useful as a means of setting the child apart from his contemporaries. ACCIDENTS AND INJURIES
This subject is introduced because it is partly developmental and is frequently overlooked. Injuries to the teeth and their sequelae are
94
TEETH
developmental because they occur mainly at two age periods when motor coordination is being tested in a new and different way. Thus the infant, after a period of aimless movement of arms and legs, followed by a quadrupedal type of locomotion, apparently feels that he is built for bipedal primate locomotion and tries it out. During this experimental period there are many physical contacts with many immovable objects. When these contacts are made by way of the child's young primary incisors, a problem is created which is frequently overlooked or minimized by the examiner. Later on in a child's life there is another testing period when body contact games and sports are being tried out. This developmental period is also fraught with dental hazards, complicated by the kind of dentition development of the individual child. Thus, when a child's permanent incisor dentition development is characterized by a protrusion of these teeth, they frequently are the first point of contact with an object directed at the mouth. The injuries produced by these accidents differ because of the development of the child. The primary teeth, being supported in less well calcified alveolar bone, tend to be dislocated and displaced. The permanent teeth of the older child tend to be fractured. The treatment of injuries to primary incisors frequently consists in repositioning the displaced tooth (or teeth) into more or less normal position in the dental arch and securing it (or them) there for a few days until supporting bone matrix can be rebuilt. This splint may be easily constructed by the dentist from self-polymerizing methyl methacrylate resin which is then cemented over the teeth with medicated zinc oxide-eugenol. Even this rapid extemporaneous treatment is unnecessary if the accident has driven the primary incisor into the alveolar process. An incisor injured in this way will re-erupt and usually take its normal place in the dental arch. There is a remote sequela of a displacement injury tv a primary incisor. Its permanent successor may be disturbed in its follicle and develop in a distorted form, either of its crown or its root, depending upon the stage of development at the time of the accident. The treatment of injured permanent incisors is a technical dental problem and need not be discussed here. Suffice it to say that such treatment is divided into an emergency phase, an intermediate phase intended to tide the patient over the adolescent developmental period, and the final phase when the patient is a young adult. The important consideration is that an accidental injury needs dental consultation at once and that the dentist is best qualified to make the diagnosis of the extent of the injury and to institute appropriate treatment. With present knowledge it is no longer enough to say, "Nothing can be done until the patient is 18 years old." A final word can be included here about prevention of dental injuries to school children who are engaging in body-contact games such as football or basketball. Such a preventive program consists in equipping a football team or a basketball team with mouth guards similar to boxers' mouthpieces, but much less cumbersome. Newer
HENRY M. WILBUR
95
latex-like materials make such a streamlined appliance feasible, and its cost is modest. The cooperation of the local dental profession is necessary in order to provide a model of each player's teeth over which the latex material is processed to make an individual mouth guard. These guards protect the players from dental injuries and are easily and inexpensively fabricated. They are certainly worth the effort in prevention of injuries which are often difficult and painful to treat as well as disfiguring. SUMMARY
As in other fields devoted to the health care of children, dental practice also has problems peculiar to youngsters as contrasted to adults. These problems are related here, as elsewhere, to growth and include such matters as abnormalities in the eruption of teeth, malocclusion or malalignment due to thumb-sucking, and injuries during various stages of growth and development. Proper management and disposition of some of these dental problems depends upon an understanding of these relations. 129 K Broadway Louisville 2, Ky.