Primary care providers are often the first contact for families and children with regard to dental care. Teething and the subsequent care of those teeth are commonly addressed during preventive care visits. Because oral health is an important part of overall health, practitioners must be comfortable providing anticipatory guidance and recommendations for the appropriate care of dentition.
As children get older, it is important to continue to assess dentition and provide age-appropriate guidance. From caries avoidance to trauma prevention, primary care providers can give information to our patients that will optimize their oral health. The primary care office or the emergency department are often the first stop for children with dental injuries, as pediatric dental care can be limited in certain areas. Because early intervention is important in many cases, health care providers need to be able to assess and manage the initial stages of dental trauma as well.
This article aims to provide clinicians with basic knowledge of dental anatomy and development, guidelines and recommendations regarding common issues related to oral health, and an understanding of acute management of dental trauma.
Dental Anatomy and Development
For providers to be able to document and discuss dentition adequately, they must be familiar with the correct dental terminology. There are two sets of teeth to be considered—the primary teeth (which eventually exfoliate) and the permanent teeth. Each tooth consists of two parts—the root, which is not visible and is located beneath the gumline; and the crown, which is the portion of the tooth that is above the gumline and visible in the mouth. Each tooth also has several layers. There is pulp in the center, dentin covering the pulp, and enamel on the outside, which is what is exposed to the environment.
Each tooth also has a name. Teeth on the upper jaw are referred to as maxillary and teeth on the lower jaw are mandibular.1 For primary teeth, starting from the center and moving toward the back are the central incisors, lateral incisors, canines, first molars, and second molars.1 For permanent teeth, starting from the center and moving toward the back are the central incisors, lateral incisors, canines, first premolars, second premolars, first molars, second molars, and third molars.1
Although there is a large acceptable range for tooth eruption, there is a general timeline and order in which teeth erupt. First are usually the mandibular incisors between ages 5 and 8 months, after which come the maxillary incisors.1 Next come the lateral incisors and then the first molars, which tend to erupt between ages 12 and 18 months.1 The canines are next, and finally the second molars erupt between ages 20 and 30 months.1 Primary dentition generally exfoliates between ages 6 and 13 years.1
Permanent teeth begin to erupt about age 5.5 years, with the first molars, then the central and lateral incisors.1 Next come the lateral incisors, first and second premolars, and then canines.1 Second molars erupt between ages 12 and 14 years and the third molars (wisdom teeth) can erupt anywhere from age 17 to 30 years.1
Establishing a Dental Home
A medical provider is often the first contact for dental care in infants and young children. One survey demonstrated that 89% of infants and 1-year-olds had seen a health care provider in the past year, whereas only 1.5% had seen a dentist.2 It is important to include a dental assessment in every well-child visit to provide anticipatory guidance regarding recommendations for oral health and appropriate referral to a dental provider.
Recommendations include regular oral examinations beginning at the time of eruption of the first tooth and no later than age 12 months.3,4 Beginning at the 1-year visit, providers should assess whether the family has a dental home and be prepared to make recommendations if one has not yet been established.5 The interval of dental examinations can then be determined based on the child's risk factors and oral health needs.3
There are several different risk assessment tools that can be used to help guide providers in identifying and referring children who are at high risk for caries formation.3 These risk assessments should begin as soon as the first tooth erupts.3 Preventive dental services not only provide monitoring but also intervention including reduction of plaque buildup, improvement of staining, and removal of calculus.3 Studies show the number and cost of dental procedures is lower in high-risk children who begin oral evaluations earlier versus those who initiate visits at a later age.3 For most children, regular dental visits are recommended every 6 months; however, those at high risk can benefit from more frequent monitoring and may need to be seen every 3 months.3
Once a child has established a dental home and risk has been assessed, the dental provider will determine the appropriate timing of radiography. This is not based on age but on a child's needs.3 Fluoride prophylaxis and sealant use will also vary depending on risk factors.3 Finally, a decision will need to be made regarding the removal or retention of the third molars (wisdom teeth).3 Evaluation with radiography should occur in late adolescence to determine the presence and position of the molars, and a decision to remove should be made and carried out by the middle of the third decade.3
Caries Risk Assessment
Dental caries is the most prevalent infectious disease in the pediatric population in the United States as well as the most common chronic disease.2,4,6 The overall incidence of dental caries has decreased in recent years, but the rates are actually increasing in young children.2,4 By kindergarten, more than 40% of children have experienced dental caries and by age 15 years this number rises to 56%.4,6 Young children are an important group to focus education and preventive measures on because early childhood caries is the greatest risk factor for caries in permanent teeth.2
Caries formation is influenced by four main factors: bacteria, sugar, saliva, and fluoride.4 First, plaque, which contains bacteria, forms on the surface of the tooth. The bacteria ferment the sugars that come from the food we eat, producing acid, which leads to conditions that demineralize the tooth enamel, resulting in caries2,4 (Figure 1). Saliva can help to buffer this low pH and also contains calcium and phosphate to remineralize the enamel.4 It also helps to flush food out of the mouth, limiting exposure of the tooth surface to sugars.4
Development of dental caries.2,4
There are different caries risk assessment models available and they include information about diet, fluoride exposure, microflora, as well as social, cultural, and behavioral factors.7 These models are designed to identify risk for both caries formation and the evolution of current lesions.7 By identifying at-risk children, we can intervene and attempt to decrease dental disease. Unfortunately, there are no risk models currently available that have shown high levels of positive and negative predictive values, so they must be utilized only as a complimentary tool for decision-making.7 Continued research and development of these models, as well as treatment protocols, will help to standardize dental care and lead to more successful outcomes and more cost-effective management.7
There are several indicators of risk for dental caries. Some of these include a primary care giver with active decay, continual bottle or “sippy cup” use (particularly at night) with fluids other than water, frequent snacking, special health care needs, lower socioeconomic status, member of a minority population, visible decalcification or white spots, and previous fillings.4,7,8 Plaque accumulation and gingivitis are also indicators of risk.7,8 Factors that are protective and contribute to lower risk of dental caries are having a dental home, drinking fluoridated water or taking fluoride supplements, fluoride varnish applied in the previous 6 months, and brushing teeth twice daily.2,7,8
Treatment of caries involves both treating active lesions and providing good guidance to prevent progression of dental disease. Studies have shown that surgical intervention does not stop the disease process and behavioral changes (eg, brushing, flossing, fluoride, decreased sugar) must also be made to reduce caries risk.7 There is emerging evidence for the use of calcium and phosphate remineralizing solutions to help reverse dental caries.7 Several fluoride compositions are also being studied in hopes of increasing the efficacy of topical fluoride applications.7
General Anticipatory Guidance
Anticipatory guidance regarding oral health should progress as children age and their dental needs change. In infancy, guidance should include information about stopping early transmission of Streptococcus mutans, avoiding prolonged nighttime feedings, and limiting the frequency of sugar-containing beverages and snacks (particularly between meals).3 In early childhood, counseling should focus on developing good oral hygiene habits (including supervised tooth brushing until age 8 years), eliminating non-nutritive oral habits (eg, pacifiers, fingers), speech development, bruxism (teeth grinding), and injury prevention.2,3,4 In addition to many of the aforementioned guidance points, adolescents often warrant discussion about the negative effects of exposure to tobacco products, the dangers of oral piercings (which are strongly opposed by the American Academy of Pediatric Dentistry [AAPD]), and dental protection with mouthguards in competitive athletics.3
Pacifiers are commonly introduced at an early age in the US, and prevalence is up to 42.5% by age 1 year.9 Providers will often be asked to give advice on pacifier use, types of pacifiers, and duration of use. It is important to note that there is some evidence that pacifiers can decrease the risk of sudden infant death syndrome.9 Pacifiers are also helpful for some children who are calmed by sucking. They also often become a comfort item similar to a blanket or stuffed animal. However, there are down sides to pacifier use, as they can cause infections (ie, thrush), shorten the duration of breast-feeding, and contribute to dental malocclusions.9
There are several concerns with regard to the dental effects of pacifier use. The most common issues are an anterior open bite (especially with pacifier use beyond age 3 years), posterior crossbite, increased overjet, increased mandibular canine arch width, decreased palate depth, and abnormal molar-canine relationships.9 For this reason, it is recommended that children stop all sucking habits by age 3 years or younger.3,4
Dental malocclusion does not seem to be affected by the type of nipple (orthodontic vs conventional).9 A thin neck nipple, however, was shown to reduce the occurrence of an anterior open bite but still contributed to increased overjet.9 The effects of pacifier use do correlate with the amount of usage. For instance, incidence of posterior crossbite was higher in children who used their pacifier both day and night compared with just one or the other.9
Juice and Juice Drink Exposure
Juice consumption and exposure of the dentition to sugar is an important determinant of caries risk in young children. Although juice and juice drink sales have declined in recent years, data from 2008 to 2013 showed that children age 2 to 18 yeas received one-half of their fruit intake from juice.10 This has improved in recent years, but consumption of juice, juice drinks, sports drinks, and energy drinks continues to be a problem and contributes to early onset of dental caries.
Care providers should be assessing and addressing the types and amounts of 100% juice, as well as juice drinks, sports drinks, and energy drinks being consumed by children. Education should be provided to families regarding the effects of these beverages on dental decay. It is also important to note that diluting with water does not decrease the dental health risk of these drinks.10 The AAPD recommends that any juice offered to toddlers should be given in a cup as part of a meal or snack.4,10 It should not be available throughout the day (which prolongs the exposure of dentition to sugar), and it should never be used to put a child to bed.4,10
Fluoride is recognized as the most effective measure in reducing dental caries in children and is endorsed by the AAPD.11 Long-term use of fluoride has reduced dental care costs for children by up to 50%.11 Fluoride works in three different ways— it promotes enamel remineralization, reduces demineralization, and inhibits bacterial metabolism and acid production.2
Fluoride is administered in three different modalities. The most expansive and beneficial distribution of fluoride has been through the addition of fluoride to community water sources.2,11 This is a safe, effective, and inexpensive way for those who drink tap water or use it to cook or prepare formula to get daily exposure to fluoride.11 A second source of fluoride is self-administration at home through toothpaste, gels, and rinses.2,11 Until age 3 years, a rice grain size amount of toothpaste is recommended, and after age 3 years a pea-sized amount is appropriate.2 Children should not be given water to rinse after brushing as they are more likely to ingest the fluoridated toothpaste and it also washes away the fluoride that remains in contact with the teeth after brushing.2 Rinses should be limited to those children who are at high risk for dental caries and are not recommended for children younger than age 6 years due to their unreliable ability to rinse and spit versus swallowing the rinse.2 In areas where fluoride is not available in the water source, oral fluoride supplementation is recommended.11 It is important to first assess all potential sources of fluoride for these children to avoid fluorosis.2 Finally, professional fluoride administration, at dental visits or in a health care office, provide additional coverage and decrease caries risk even further.2,11 Current recommendations are for application every 3 to 6 months depending on individual risk factors.2 Children should eat soft foods and avoid brushing their teeth until the next morning after application of fluoride varnish to allow maximal effect.2
Although the topic of fluoridation of community water sources is debated and a controversial topic, it has been found to be extremely safe and effective. It has been shown to decrease tooth decay by 29% and it has been hailed as one of the top ten public health achievements of the 20th century.2 The main concern with fluoride exposure is the risk of fluorosis in patients who are exposed to excessive fluoride during the time that enamel is forming on the teeth (primarily in children younger than age 8 years).2 When it does occur, fluorosis is generally mild and consists of white striations or opaque areas on the teeth.2 More severe forms of fluorosis are rare but can have a structural impact on the teeth including pitting, brittle edges, and weakened groove anatomy.2
About 25% of school-aged children experience some sort of dental trauma.4,12 Eighty percent of those who present to the emergency department with dental injuries are younger than age 18 years,13 and about 32% of these injuries occurred during sports activities.13 Baseball (in children age 7–12 years) and basketball (in children age 13–17 years) are the sports with the most dental injuries reported.13 The bicycle is the most common piece of sporting equipment implicated in dental injury.13 In the majority of sporting-related injuries, children were not wearing a mouthguard or other protective equipment even though studies show that these can significantly reduce the incidence of dental trauma.13 The American Dental Association recommends mouthguard use in 29 sports and activities.12,13 Despite this, in the US, only high school football, lacrosse, hockey, field hockey, and wrestlers who wear braces are required to use protective equipment to reduce dental injury.13 Oral injuries tend to occur more often in boys and less often in professional athletes.12,13 Injuries are also much more prevalent during competition than during practice or training.13
The most common location for oral injury is the upper lip, maxilla, and maxillary incisors, accounting for 50% to 90% of all dental injuries.13 The most common types of injuries are lacerations, crown fractures, and avulsions.13
There are many different types of dental trauma and treatment depends on whether the tooth is a primary or permanent tooth. For all injured teeth that do not require immediate treatment, there should be close monitoring for discoloration or infection.12 Injuries can be grouped into three categories: concussions, displacements, and fractures (Table 1).
Dental Trauma and Treatment
Concussed teeth are tender to touch but there is no increased mobility or displacement of the tooth.12 There is generally no bleeding at the margin of the tooth and gums.12 Concussed teeth, both primary and permanent, require no treatment.
Displaced teeth are categorized based on the degree and direction of displacement. The first in this category is subluxation, in which there is some abnormal mobility of the tooth but no displacement and there is often some bleeding present.12 This injury also requires no treatment but close monitoring.12 Next, there is lateral luxation in which the tooth is displaced laterally.12 This type of injury can leave the tooth mobile or firmly locked into the abnormal position.12 If the tooth is a primary tooth and the displacement is mild, gentle repositioning of the tooth is appropriate. You can also leave it in the displaced position as long as it does not interfere with the bite, and repositioning will often occur naturally.12 If the tooth is more extensively displaced or is interfering with the bite, it should be extracted.12 For permanent teeth, lateral luxation calls for gentle repositioning and stabilization with a splint for about 4 weeks.12 Extrusive luxation (or partial avulsion) is vertical displacement of the tooth.12 If displacement is minor the tooth should be gently repositioned, and if permanent it should be splinted.12 If more severe, the tooth may require extraction.12 Intrusive luxation is when the tooth is forced into the alveolus and appears shortened or absent.12 These typically re-erupt on their own and can be monitored.12 If the provider is unsure if the tooth is present (not avulsed), a radiograph is indicated. If the tooth has not erupted after a few weeks, manual repositioning may be needed and the patient should be evaluated by a dental professional.12 The next type of injury is avulsion, which is complete displacement of the tooth out of the socket.12 For primary teeth, no treatment is indicated, although a spacer may be helpful in preserving tooth positioning.12 For permanent teeth, immediate reimplantation is indicated.12
The handling of permanent avulsed teeth is important to preserve the potential for reimplantation.12 The tooth should be handled only by the crown, washed under cold water for 10 seconds, and replanted immediately.12 The child should then bite on a cloth to hold the tooth in place on the way to the dentist or ER.12 If reimplantation is not possible, the tooth should be stored in cold milk or saliva.12 The tooth will be splinted and will often require a root canal within the first 2 weeks after reimplantation.12
The final category consists of fractures, and these are categorized based on the location and depth of the fracture. First is an infraction in which only the surface of the enamel is cracked.12 Treatment of primary and permanent teeth is a resin sealant to avoid obvious staining or no treatment at all.12 Next is an uncomplicated crown fracture involving only the enamel.12 This often has limited sensitivity and can be smoothed with a dental handpiece and polishing bur if needed.12 If the enamel and dentin are affected, the tooth should be restored with dental material within a few days to reduce sensitivity.12 Complicated crown fractures involve all layers down to the pulp, are sensitive, and have a higher risk for infection.12 For primary teeth, pulpotomy or pulpectomy and restorative care is indicated.12 If the child is unable to tolerate this, then extraction is the treatment.12 For permanent teeth, pulp therapy should be done immediately and the patient may need a root canal.12 A root fracture requires referral to a dental professional, and treatment is based on the location of the fracture.12 The closer the fracture is to the apex of the root, the better the outcome, and often no treatment is needed.12 For fractures closer to the crown, splinting is done, and if the tooth is still mobile after 4 weeks then the crown is removed.12 Finally, there are alveolar fractures that present clinically as dislocation of several teeth.12 They require stabilization with a splint and referral to a dentist or oral surgeon for repositioning and placement of stabilization wires.12
Health care providers play an important role in promoting good oral health (Table 2). Not only are they often the first point of contact for dental management in infants and young children, they are often the first to evaluate dental trauma as well. They must be able to provide good guidelines for caries prevention, age-appropriate anticipatory guidance regarding dentition, and appropriate referral to a dental home. The more comfortable providers are with dental questions and concerns, the better care they can provide to their patients.
Quick Tips for the Provider
- Logan WHG, Kronfeld R. Development of the human jaws and surrounding structures from birth to the age of fifteen years. J Am Dent Assoc. 2003;20:379–427.
- Clark MB, Slayton RL. Fluoride use in caries prevention in the primary care setting. Pediatrics. 2014;134:626–633. doi:. doi:10.1542/peds.2014-1699 [CrossRef]
- American Academy of Pediatric DentistryCouncil on Clinical Affairs. Periodicity of examination, preventive dental services, anticipatory guidance/counseling, and oral treatment for infants, children, and adolescents. http://www.aapd.org/media/Policies_Guidelines/BP_Periodicity.pdf. Accessed December 13, 2018.
- Section on Oral Health. Maintaining and improving the oral health of young children. Pediatrics. 2014;134(6):1224–1229. doi:. doi:10.1542/peds.2014-2984 [CrossRef]
- Committee on Practice and Ambulatory Medicine; Bright Futures Periodicity Schedule Workgroup. 2017 Recommendations for preventive pediatric health care. Pediatrics. 2017;139(4):e20170254. doi:. doi:10.1542/peds.2017-0254 [CrossRef]
- American Academy of Pediatric DentistryCouncil on Clinical Affairs. Policy on oral health care programs for infants, children, and adolescents. http://www.aapd.org/media/policies_guidelines/p_oralhealthcareprog.pdf. Accessed December 13, 2018.
- American Academy of Pediatric DentistryCouncil on Clinical Affairs. Caries-risk assessment and management for infants, children, and adolescents. http://www.aapd.org/media/Policies_Guidelines/BP_CariesRiskAssessment.pdf. Accessed December 13, 2018.
- American Academy of Pediatrics. Oral health risk assessment tool. https://www.aap.org/en-us/Documents/oralhealth_RiskAssessmentTool.pdf. Accessed December 13, 2018.
- Schmid KM, Kugler R, Nalabothu P, Bosch C, Verna C. The effect of pacifier sucking on orofacial structures: a systematic literature review. Prog Orthod. 2018;19(1):8. doi:. doi:10.1186/s40510-018-0206-4 [CrossRef]
- Heyman MB, Abrams SASection on Gastroenterology, Hepatology, and Nutrition; Committee on Nutrition. Fruit juice in infants, children, and adolescents: current recommendations. Pediatrics. 2017;139(6):e20170967. doi:. doi:10.1542/peds.2017-0967 [CrossRef]
- American Academy of Pediatric DentistryCouncil on Clinical Affairs. Policy on use of fluoride. http://www.aapd.org/media/policies_guidelines/p_fluorideuse.pdf. Accessed December 13, 2018.
- Keels MASection on Oral Health, American Academy of Pediatrics. Management of dental trauma in a primary care setting. Pediatrics. 2014;133:e466–e476. doi:. doi:10.1542/peds.2013-3792 [CrossRef]
- American Academy of Pediatric DentistryCouncil on Clinical Affairs. Policy on prevention of sports-related orofacial injuries. http://www.aapd.org/media/Policies_Guidelines/P_Sports.pdf. Accessed December 13, 2018.
Dental Trauma and Treatment
Treatment for Primary Teeth
Treatment for Permanent Teeth
||Displacement laterally ± mobility
||Mild: gentle repositioning or leave as is if not interfering with bite
Severe: if interfering with bite, extract
||Gentle repositioning and splint
||Minor: gentle repositioning
||Gentle repositioning and splinting
||Tooth is forced into the alveolus and appears shortened or absent
||Monitor: re-erupt on own
May need radiograph to determine if still there
After weeks may need repositioning
||Monitor: re-erupt on own
May need radiograph to determine if still there
After weeks may need repositioning
||Complete displacement of tooth out of socket
Spacer if patient sucks thumb or pacifier
||Enamel surface crack
|Uncomplicated crown fracture
||Involves enamel only or enamel and dentin
Enamel and dentin: restore
Enamel and dentin: restore
|Complicated crown fracture
||Enamel, dentin, and pulp
||Pulpotomy/pulpectomy and restoration
||Pulp therapy and often root canal
||Near apex or near crown
||Multiple dislocated teeth
||Splint and refer to dentist or oral surgeon
||Splint and refer to dentist or oral surgeon
Quick Tips for the Provider
Encourage establishment of a dental home by age 1 year3
Recommend cessation of all non-nutritive sucking by age 3 years3
Limit juice consumption and never give juice outside of a meal or snack10
Encourage fluoride exposure through drinking tap water, brushing with fluoridated toothpaste, and application of professional fluoride treatments11
Be familiar with first-line dental trauma management and know when to refer to a dental provider