Chapter 3. Oral Diseases and Conditions
in Young Children
Oral health affects general health and vice versa. This chapter
provides a brief overview of some of the more common conditions
and diseases that can affect young children's oral health.
Dental caries, infectious diseases, manifestations of systemic
disease, soft tissue abnormalities, tooth anomalies and craniofacial
syndromes are covered. This chapter is geared primarily to
This Rural Smiles chapter is an overview of major concepts
and clinical information about oral conditions in young children.
While Chapter 4 focuses on specific clinical measures to prevent
dental caries in young children, this chapter focuses more
on approaches and resources for assessing risk factors and
protective factors for oral conditions and diseases and recognizing
clinical signs and symptoms at an early stage. Chapter 7 provides
additional suggestions for public education approaches and
anticipatory guidance, while Chapter 11 shows how prevention,
early detection, education and treatment can be combined in
viable programs and clinical practice. More in-depth information,
including color photos and videos, can be found in other online
manuals or websites. One source is the California First 5
Oral Health Initiative website, which includes multiple avenues
for increasing your knowledge about early childhood caries.
Another source is A
Health Professional's Guide to Pediatric Oral Health Management,
an online course with 7 modules. Their Chapter 3 module walks
you through the oral examination process for a young child
and shows photos of normal and abnormal conditions. It is
mainly targeted to "non-dental" health professionals
who want to increase their knowledge of oral health issues
for young children. A fact sheet, Oral
Conditions in Children with Special Health Needs covers
various conditions, and is also targeted to health professionals.
Go to http://www.mchoralhealth.org/PediatricOH/mod3.htm
and take the self-assessment knowledge quiz for Chapter 3
of the online course A Health Professional's Guide to Pediatric
Oral Health Management. Then come back to this chapter and
do the Oral
Conditions self-assessment that looks more at your experience
and confidence for recognizing oral health problems and referring
for primary dental care or specialty care.
Oral Health and General Health
Oral health is an integral part of overall health. This is
an important concept that is reflected in numerous reports
and is a key message of the California First 5 Oral Health
Initiative. Oral Health in America: A Report of the Surgeon
General (2000) discusses the following aspects of this concept.
- The mouth reflects general health and well-being.
- Oral diseases and conditions are associated with other
health conditions and affect health and well-being throughout
- Safe and effective measures exist to prevent many oral diseases.
The Children's Dental Health Project in Washington, DC,
in their report, The Interface Between Medicine and Dentistry
in Meeting the Oral Health Needs of Young Children,
further discusses the interactions between oral health and
general health, as well as social determinants and outcomes
"To the extent that children's
oral health problems are considered in isolation from
the rest of children's health and social policy, effective
solutions cannot be generated."
"Children under the age
of 5 are at a seminal state vis-a-vis their physical
and cognitive development. They are going through
a period of life during which decisions about their
health, nutrition, education, socialization, and other
basic aspects of their existence are likely to have
lifelong consequences. Because of this, deferral of
investments in their health and welfare made during
this period can often have long-term deleterious effects."
The following statements highlight possible outcomes from
- Children who cannot verbalize or otherwise indicate
that they are in pain may experience severe oral problems
that go untreated.
- Chronic dental/oral pain can lead to distractibility,
withdrawal, depression and deterioration of school performance;
this can negatively affect self-esteem.
- Untreated dental disease can cause decreased appetite,
failure to thrive and sleep deprivation.
- Compared to children from high income families, children
from low-income families miss nearly 12 times as many days
from school because of dental problems.
The most common infectious disease of childhood is dental
caries (tooth decay). It is 5 times more common than asthma
and 7 times more common than hay fever. Nationally, 18%
of children aged 2 to 4 already have dental caries that
can be seen during a simple visual exam. Percentages are
higher in certain populations, especially children from
low-income families. About 25% of those are considered to
be at "high risk" for dental caries
Dental caries is a chronic infectious disease that generally
progresses slowly (but sometimes rapidly), usually is not
self-limiting, and advances to destroy the tooth unless
some form of treatment is initiated. Treatment can be "preventive"
in nature if the decay process is at a stage where tooth
structure can be reversed to a healthier state. The treatment
is "restorative" if the diseased tooth structure
is removed and replaced with a "filling." Other
terms that are used to describe dental caries include:
- Primary caries: an initial area of decay on a tooth
- Secondary caries: decay develops around an area that
already has been filled
- White spot lesion: how an initial cavity looks on
the tooth (white and opaque)
- Rampant caries: rapidly advancing decay on multiple teeth;
early childhood caries is one example.
Left untreated, dental caries can cause further infection,
especially abscesses, cellulitis, tooth loss, and in very
severe cases, or in children who are medically compromised,
can be life threatening.
Important components and concepts of dental caries
"…the processes involved
in dental caries are highly complex, with temporal
and spatial variations, not only in the number and
type of determinants involved, but also in their relative
influence…such inputs as the times, lengths,
frequencies, and types of sugar composition, the quality
of tooth cleaning, the fluctuations in salivary flow
rates and composition, and the quality and composition
of biofilm are themselves so highly variable…"
O and Kidd EAM. Dental Caries. The Disease and its
Malden, MA: Blackwell Munksgaard, 2003.
Saliva plays multiple roles in oral health and disease:
helping clear food and bacteria from the mouth, protecting
teeth by neutralizing acids, maintaining calcium phosphate
concentrations, helping form a protective "pellicle"
(film) on the tooth, defending against microbial attack.
Decreased levels of saliva can result in increased rates
of dental caries.
Oral microflora. Babies are born with sterile mouths
but quickly acquire organisms (microflora) primarily through
saliva, usually from their mothers. The diversity of this
microflora increases in the first few months. As the teeth
erupt, bacteria are able to attach to them and are less
apt to be swept from the mouth, so large colonies are formed
(plaque). As the child matures, the microflora mature and
reach an equilibrium. When the equilibrium is disrupted,
then disease can occur. Young children can be highly susceptible
to initiation of dental caries. Cleaning the teeth, tongue
and other soft tissues at least once a day in young children
is important. K?hler et al, (1984) demonstrated that reducing
mutans streptococci levels in mothers can prevent transmission
to their infants.
Microhabitats. There are various habitats for bacteria
to live in the mouth:
- Mucosa (e.g, palate, cheek, tongue): the tongue harbors
many bacteria on its surface
- Tooth surfaces (smooth, pits and fissures, between
the teeth): the pits and fissures are most prone to decay
- Gingival crevice: the area that forms a pocket where the
gum tissue meets the tooth
Diets rich in carbohydrates, either from food or beverages,
increase the growth rates of many oral microflora, and can
also create an acidic environment that fosters the decay
process. Formula, breast milk, and other milk products can
also create an acidic environment. Chemical interactions
occur between teeth and saliva. These interactions can cause
demineralization of the tooth structure, but also allow
use of substances such as fluorides to prevent or reverse
this process. The following figure shows the balance between
tooth demineralization and mineralization, and some of the
factors that tip the scale.
Teeth can display a number of variations that are caused
by genetic or environmental influences during tooth formation.
Most are cosmetic concerns, while others (such as multiple
missing or misshapen teeth) may cause functional problems
with eating or clear speech.
- Number: Some children may have supernumerary teeth
(extra teeth) or may be missing one or more teeth.
- Size: tooth size is largely genetic, but small teeth
or fused teeth can also result from interrupted formation.
- Shape: either the crown (visible part of the tooth)
or the root can experience anomalies.
- Structure: the enamel (outer layer) of the tooth
is sensitive to environmental influences (e.g., infection,
trauma) during formation. Two common conditions are hypoplasia
(pits on the surface) and hypocalcification (whitish spots).
- Color: color changes can occur from intrinsic stains
(inside the tooth structure) such as blood-borne pigments,
drugs (e.g., tetracycline), anemia and other situations,
or as extrinsic stains (on the tooth surface) from iron
supplements, bacteria, food, etc. Extrinsic stains can be
- Eruption patterns: primary and permanent teeth generally
erupt in a usual sequence and timeframe. View an eruption
chart. There can be wide variations, however, some of
which may require orthodontic care.
Soft Tissue Problems
The soft tissues inside the mouth can reflect infections
as well as signs of systemic diseases or disorders. Children
with HIV can show oral manifestations, mostly opportunistic
infections (yeast) and other indications of a compromised
immune system. Children with blood disorders and dyscrasias
can have problems with oral bleeding. As teeth are erupting,
cysts can form with an accumulation of blood, making a small
bluish sack above the erupting tooth. The dentist may create
a small opening for the tooth so that the tooth eruption
cycle is not interrupted. If teeth or soft tissues become
infected or diseased, an abscess can occur. If dental in
origin, the tooth may be tender to pressure, painful and
slightly mobile. Soft tissue abscesses generally resemble
small, soft, red or yellow nodules with pus and may be tender.
They can occur from infection of the pulp of the tooth or
a foreign object. Both types can progress rapidly to cellulitis
and can affect any developing permanent teeth. The infection
must be eliminated and antibiotics will usually be recommended.
Herpes is a very common viral disease that is characterized
by multiple vesicles on the tongue, lips and gum tissue
that rupture and form ulcers that are painful and bleed
easily. They go away after 7-10 days, but can recur periodically
throughout life, usually as single lesions on the lips or
corners of the mouth. In children, the goal is to control
fever, pain, and transmission to others and to prevent dehydration
with increased intake of fluids. Oral lesions from the virus
that causes chickenpox are also common. If children have
been sexually abused, sexually transmitted diseases may
appear in the mouth and need to be treated. Candida (yeast)
infections in newborns or infants appear as white clusters
on the tongue or palate that bleed if scraped. Antifungal
agents are generally recommended.
The sensitive tissues of the mouth can also react to allergens
(e.g., food, chemicals) with local or diffuse reddening,
ulcerations and there may be a burning sensation or pain.
The goal is to identify and eliminate the allergen; sometimes
topical medications are used to alleviate pain. Ulcers can
also form from chemical sources (cleaning fluids), thermal
(hot foods or beverages), electrical (electric cord burns)
or mechanical injuries (trauma from an object). They can
be single red or yellow lesions of different sizes and shapes,
most often on the tongue, cheeks, lips and palate. If not
severe, medications for symptomatic relief are given, and
the lesions heal fairly rapidly.
Unintentional injuries are common in children, especially
from falls, and can cause contusions and injuries to both
the soft and hard tissues of the face and mouth. A good
reference to learn how to handle dental emergencies is the
Physician's Guide to Dental Emergencies, (order for $20
+ tax through the Dental Health Foundation website, http://www.dentalhealthfoundation.org.)
Craniofacial Syndromes And Other Genetic Disorders
A number of disorders can occur at birth that have accompanying
oral and dental implications. The most common one is cleft
lip and/or palate, which affects about 1 out of 600 live
births for whites and 1 out of 1,850 live births for African
Americans. Down Syndrome children have facial abnormalities,
changes in tooth shape and are more susceptible to gingival
infections. Children with Fragile X syndrome also have facial
bone and tooth abnormalities. To learn more about other
syndromes and genetic disorders, refer to some of the pediatric
dentistry references in the Resources section.
In the discussion on dental caries, you learned that dental
caries occurs when the environment in the mouth goes out
of equilibrium to one that initiates the process of demineralization.
The equilibrium state has been referred to as the "caries
balance", when pathological factors and protective
factors are equal (Featherstone, Feb 2003). Assessing what
factors might push the equilibrium out of balance in any
particular child is called "risk assessment".
Major risk factors and protective factors for children ages
0-5 are listed in the boxes. Children with special health
needs may have additional risk factors based on their specific
medical diagnoses. Work closely with caretakers and healthcare
providers to identify these factors. The factors can be
used to create individual care plans for children and to
develop a profile of specific groups of children to plan
the best community-based prevention programs and allocate
resources for clinical dental care. Chapter 11 puts risk
assessment into the context of a total infant/child oral
Risk Factors for Dental
- Caretaker has untreated decay
- Reduced salivary flow
- Frequent ingestion of fermentable
- Less than optimal fluoride
- Significant bacterial challenge
- Poor oral hygiene care
Protective Factors for Dental
- No previous caries
- Normal salivary flow and consistency
- Balanced diet low in fermentable
carbohydrates and acidic beverages
- Optimal fluoride use
- Low bacterial challenge
- Use of antimicrobials
- Good oral hygiene care
A number of risk assessment forms have been developed,
and recommendations/policies made for roles that health
professionals, dental professionals, caregivers and others
might play in this process. Refer to the following resources
for specific information:
- American Academy of Pediatrics. Policy on Oral Health Risk
Assessment Timing and Establishment of the Dental Home: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;111/5/1113
- American Academy of Pediatric Dentistry. Risk Assessment
Policy and Tool: http://www.aapd.org/pdf/policycariesriskassessmenttool.pdf
- Chapter 2 of A Health Professional's Guide to Pediatric
Oral Health Management: http://www.aapd.org/pdf/policycariesriskassessmenttool.pdf
- Featherstone JDB et al. Caries management by risk assessment:
Consensus statement, April 2002. CDA Journal. 31(3):257-69,
- Oral Health Red Flags Checklist, Kids Get Care program,
Seattle, WA, http://www.metrokc.gov/health/kgc/redflags-checklist.doc,
designed for teachers, caretakers, childcare workers, etc.
Note that some of these tools primarily address dental
caries rather than the other oral diseases and conditions,
because caries is the biggest oral health problem in young
children. Programs should not ignore the other oral problems
such as soft tissue infections and oral injuries, however.
Questions about these factors can be incorporated into a
risk assessment. The reference Bright
Futures in Oral Health provides examples of risk assessment
for some of these other conditions. The rest of the publication
includes questions to use as well as recommendations for
counseling and follow-up. (This publication will be undergoing
updates in the near future to reflect the ever-changing
Key messages from this chapter are:
1. Dental caries is a transmissible bacterial infection.
2. Risk assessment can help identify what risk factors and
protective factors exist, and how they might be used to
prevent, reverse or reduce dental caries in young children.
3. Soft tissues in the mouth can reflect more general infections,
signs of systemic diseases, or reactions to allergens.
4. Disorders of teeth can be reflected in changes in number,
size, shape, structure, color or eruption patterns.
5. A number of congenital or genetic disorders have accompanying
oral and dental manifestations.
6. Health professionals can play an important role in helping
to prevent and treat oral diseases and conditions in young
Berkowitz RJ. Acquisition and transmission of mutans streptococci.
CDA Journal. 31(2):135-38, 2003. http://www.cdafoundation.org/journal/jour0203/berkowitz.htm
Bird WF. Caries protocol compliance issues. CDA Journal.
31(3):252-56, 2003. http://www.cdafoundation.org/journal/jour0303/bird.htm.
Children's Dental Health Project. The Interface Between
Medicine and Dentistry in Meeting the Oral Health Needs
of Young Children. Washington, DC: CDHP, 2003.
Clinical Guideline on Oral and Dental Aspects of Child
Abuse and Neglect, 1999. http://www.aapd.org/members/referencemanual/pdfs/02-03/G_Childabuse.pdf
Featherstone JDB. The caries balance: Contributing factors
and early detection. CDA Journal. 31(2):129-33, 2003. http://www.cdafoundation.org/journal/jour0203/featherstone.htm
Fejerskov O and Kidd EAM. Dental Caries. The Disease and
its Clinical Management. Malden, MA: Blackwell Munksgaard,
Kohler B, Andreen I and Jonsson B. The effect of caries-preventive
measures in mothers on dental caries and the oral presence
of the bacteria Streptococcus mutans and lactobacilli in
their children. Arch Oral Biol. 29:879-83, 1984.
Levy AM, Warren JJ, Broffitt B, Hillis SL and Kanellis
MJ. Fluoride, beverages and dental caries in the primary
dentition. Caries Res. 37:157-65, 2003.
Marsh PD. Microbial ecology of dental plaque and its significance
in health and disease. Adv Dent Res. 8:263-71, 1994.
Murdoch-Kinch CA and McLean ME. Minimally invasive dentistry.
J Am Dent Assoc. 134:87-95, Jan 2003. Good overview of emerging
technologies and scientific advances that are changing dental
caries prevention, detection and treatment.
Oral Health and Learning. National Maternal and Child Oral
Health Resource Center.
Pinkham JR, Casamassimo PS, Fields HW, McTigue DJ and Nowak
A, eds. Pediatric Dentistry. Infancy through Adolescence.
3rd edit. Philadelphia, WB Saunders, 1999.
Promoting Awareness, Preventing Pain: Facts on Early childhood
Caries (ECC), 2nd ed, National Maternal and Child Oral Health
Resource Center. http://www.mchoralhealth.org/PDFs/ECCFactSheet.pdf.
Schechter N. The impact of acute and chronic dental pain
on child development. J Southeastern Soc of Pediatr Dent.
Stewart RE and Hale KJ. The paradigm shift in the etiology,
prevention and management of dental caries: Its effect on
the practice of clinical dentistry. CDA Journal. 31(3):247-51,
USDHHS. Oral Health I America: A Report of the Surgeon
General. Rockville, MD: USSDHHS, NIDCR, NIH, 2000. http://www.nidcr.nih.gov/sgr.htm.
What did you learn or accomplish as a result of reading
this chapter? Do you have a better feeling for how oral
health is an integral part of overall health? Were the resources
and examples helpful? Complete the feedback form for Chapter 3 and tell us what was useful and not useful for