Subjects and Methods



Review of Literature

Oral health of children is important to their overall well-being. The mouth cannot be separated from the rest of the body, oral health cannot be considered separate from the rest of children's health. Oral health actually includes all the sensory, digestive, respiratory structural and emotional functions of the teeth. Oral health must be considered in the context of social, cultural, and environmental factors. Dental disorder have a profound impact on children, and the burden of untreated dental health problems is substantial. Untreated dental cavities can result in pain, infection, tooth loss, difficulty eating or speaking, and poor appearance, all of which present challenges for maintaining self-esteem and attentiveness to learning (Maas, 2010).

Anatomy and physiology of oral cavity

The oral phase includes all swallowing activities that occur within the oral cavity. It can be divided into preparatory and transfer phases. The oral cavity is bounded by the lips anteriorly; the cheeks laterally; the teeth, alveolar ridge, hard palate, and soft palate anteriorly; the teeth, alveolar ridge, floor of mouth, and tongue inferiorly; and the soft palate, uvula, tonsillar pillars, and posterior part of the tongue that form the posterior opening of the oral cavity or the oropharyngeal isthmus (Massey, 2006). In the mouth, a combination of hard and soft tissue areas form the occlusion (bite). The teeth, along with upper and lower jaw bones, are among the hard tissues. The soft tissue includes the gums, tongue, and salivary glands (Swain, 2009).

Teething

A tooth or teeth come through the gum line (tooth eruption). This is a normal process of the body. The first set of teeth a child has is called the primary or deciduous teeth. As a child loses the primary teeth, the second set of teeth, known as the permanent or secondary teeth, comes through the gum line. Teeth are named for their location in the mouth and the function they serve. Incisors cut the food, and canines tear the food. Premolars crush the food, and permanent molars grind the food (Mclaughlin and Pizzi, 2009).

The child may have some discomfort. The baby’s gums may become sore and irritated, and may become cranky or fussy. To help reduce the irritation suggests rubbing baby’s gums with a clean finger. Gently massaging the area will help the discomfort of baby’s mouth. Letting child chew on something cold (like a chewing ring) will help a lot. The teething process will not make child ill. It often seems that child has a cold or mild fever along with the drooling and chewing (Sciarra, 2005). When Teething gels, biting on something hard (such as a teething ring), paracetamol or ibuprofen seem to help some babies. Not use lemon juice on baby's gums. Lemon juice has a lot of acid and can harm new teeth by dissolving the tooth enamel (Wake and Hesket., 2009).

Fig (1): Eruption tooth cutting through

[pic]

Wale, J. (2010): Human teeth.p4.Wikimedia .22/5/2010. Available on:

Eruption of primary teeth

The tooth breaking through the gum line. In babies, tooth eruption is also called teething. The timing of tooth eruption differs from one child to the next. While the timing may vary, the order of tooth eruption is generally the same. Generally, the average child has their full set of 20 primary teeth by the age of three years (ADA, 2008).

Fig (2): Child have erupted tooth

[pic]

Table (1): Primary teeth eruption

The following table shows when the primary teeth (baby teeth) erupt. It is important to note that the eruption time varies from one child to another (Wale, 2010).

|Primary teeth |

|Upper Teeth |Eruption Time |Lower Teeth |Eruption Time |

|Central Incisor |8 to 12 months |Central Incisor |6 to 10 months |

|Lateral Incisor |9 to 13 months |Lateral Incisor |10 to 16 months |

|Cuspid |16 to 22 months |Cuspid |17 to 23 months |

|First Molar |13 to 19 months |First Molar |14 to 18 months |

|Second Molar |25 to 33 months |Second Molar |23 to 31 months |

Wale, J. (2010): Human teeth.p4.Wikimedia .22/5/2010. Available on:

Fig (3): Primary teeth chart

[pic]

Jain, R.K. (2010): Anatomy and development of the mouth and teeth. Lucile Packard children hospital. California. p2. Available on

Permanent teeth

The permanent teeth start to develop in the jaws after a child is born. By about 21 years, the average person has 32 permanent teeth: 16 in the upper jaw and 16 in the lower jaw. Permanent teeth are also known as adult teeth or secondary teeth (ADA, 2008).

Table (2): Permanent teeth eruption

The following table shows when the permanent teeth (adult teeth) erupt (Wale, 2010).

|Permanent teeth |

|Upper Teeth |Eruption Time |Lower Teeth |Eruption Time |

|Central Incisor |7 to 8 years old |Central Incisor |6 to 7 years old |

|Lateral Incisor |8 to 9 years old |Lateral Incisor |7 to 8 years old |

|Cuspid (Canine) |11 to 12 years old |Cuspid (Canine) |9 to 10 years old |

|First Bicuspid (Premolar) |10 to 11 years old |First Bicuspid (Premolar) |10 to 12 years old |

|Second Bicuspid (Premolar) |10 to 12 years old |Second Bicuspid (Premolar) |11 to 12 years old |

|First Molar |6 to 7 years old |First Molar |6 to 7 years old |

|Second Molar |12 to 13 years old |Second Molar |11 to 13 years old |

|Third Molar (Wisdom Tooth) |17 to 21 years old |Third Molar (Wisdom Tooth) |17 to 21 years old |

Wale, J. (2010): Human teeth.p4.Wikimedia .22/5/2010. Available on:

Fig (4): Permanent teeth chart

[pic]

Jain, R.K. (2010): Anatomy and development of the mouth and teeth. Lucile Packard children hospital. California. p2. Available on

Teeth Types

The teeth in an adult are divided into four categories-incisors, canines, premolars and molars. Incisors are single-rooted teeth with a sharp, thin edge. These teeth are located at the front of the mouth and are designed to cut food. The tongue side of an incisor is shaped like a shovel to help guide food into the mouth. Canines, also known as cuspids, are located at the "corner" of a child dental arch. The canines cut and tear foods. The canines are the longest teeth in the human mouth and thus also are some of the most stable teeth. Premolars, also called bicuspids, are a cross between canines and molars and sit behind the canines. These teeth have pointed cusps on their cheek side that hold the food, while the cusps on the tongue side grind it. Molars are called (wisdom teeth), are the last teeth, farthest back in the mouth on all sides. In between are the second molars, also called 12-year molars. Molars are large teeth with broad surfaces designed for crushing, grinding and chewing food. On the upper jaw, the molars have three well-separated roots; on the lower jaw, the molars have two roots (Bird and Robinson., 2009).

Fig (5): Human teeth

[pic]

Wale, J. (2010): Human teeth.p4.Wikimedia .22/5/2010. Available on:

Fig (6): Structure of teeth (Parts of tooth)

[pic]

Urquhart, D. (2010): The development and structure of tooth and teeth. Tooth and .p1.A

• Cementum - a layer of tough, yellowish, bone-like tissue that covers the root of a tooth. It helps hold the tooth in the socket (Nagel, 2009). Cementum is almost as hard as enamel, but also continues to grow throughout life from cells in the pulp. This allows for continual reattachment of the periodontal ligament to the bottom of the tooth, and provides for a measure of healing for victims of periodontal disease if caught early enough. It's only found on the underside of the tooth, below the gum layer, and is thickest at the bottom point of the tooth (Urquhart, 2010).

• Crown - the visible part of a tooth (Nagel, 2009).

• Dentin - the intermediate tooth layer, the dentin is harder than bone. The Dentin is a spongy, porous form of specialized bone created to provide shock absorbing cushions for dental enamel, which is quite brittle (Nagel, 2009). It surrounds the entirety of the pulp and is capped by dental enamel above and cementum below the gum line. Dentin also continues to grow throughout life. It's also much more susceptible to quick decay and damage because of its delicate internal structure (Urquhart, 2010).

• Enamel - the hard shiny, white outer surface of the tooth, it is hydroxyapatite, which is a crystalline calcium phosphate (Nagel, 2009). Dental enamel covers the entire top of the tooth, and is very hard, very brittle, and slightly translucent. If the underlying dentin has started to decay or change color, the change is frequently visible through the enamel. Because dental enamel has a very dense mineral structure, it's highly susceptible to acidic damage, which is how most cavities start. In addition, dental enamel can be worn away by other acids such as lemon juice and excessive abrasion from dental hygiene efforts (Urquhart, 2010).

• Nerves & Pulp - nerves transmit signals (conveying messages like hot, cold, or pain) to and from the brain, the soft center of the tooth. The pulp contains blood vessels and nerves; it nourishes the dentin (Nagel, 2009).

• Periodontal membrane/ligament - the fleshy tissue between tooth and the tooth socket; it holds the tooth in place (Nagel, 2009). The periodontium is the supporting structure of a tooth, helping to attach the tooth to surrounding tissues and to allow sensations of touch and pressure. It consists of the cementum, periodontal ligaments, alveolar bone, and gingiva. Alveolar bone surrounds the roots of teeth to provide support and creates what is commonly called an alveolus, or "socket". Lying over the bone is the gingiva or gum, which is readily visible in the mouth (Iverson, 2010).

• Root - the anchor of a tooth that extends into the jawbone. The number of roots ranges from one to four (Nagel, 2009).

Nutrition and dental health

Adequate nutrition provides the basis for development of all tissues and structures of the body including those in the oral cavity (Palmer, 2007). Good nutrition is essential for good physical health. Nutrition also plays a key role in the development and maintenance of a healthy mouth, especially the teeth and gums. Good dental health begins early in life and must be practiced throughout life. Tooth development begins shortly after conception, usually between the sixth and eighth weeks of gestation and continues throughout pregnancy. It seems to take severe nutritional deficiencies in the mother to cause obvious changes in tooth formation in the child. However, slight deficiencies may cause changes in tooth structure that will leave a tooth at greater risk for decay later in life (Anderson and Brown., 2008).

Effects of specific nutrients on developing dentition

• Fluoride is one of the essential elements for a good dental health. It helps teeth fight against plague and can neutralize harmful effects of acids in saliva. Receive great amounts of fluoride from water and tea consume regularly. Also, this element can be found in walnuts, fish and other foods (Matz, 2010).

• Protein helps teeth form. Kids who don't get enough protein and are malnourished have a higher risk for cavities. Choose lean sources of protein like fish, chicken and beans. These foods are also high in iron, magnesium and zinc, which help to build teeth and bones (Matz, 2010).

• Iron deficiency can cause gum problems and bring to gums inflammation. Liver, red meat, beans, apples and other products are prefect sources of iron (Palmer, 2007).

• Calcium this element protects teeth against tooth enamel damages and the effects of temperature changes. Lack of calcium in body, teeth can start crumbing. Therefore, it is vital for good dental health to eat the foods with high content of calcium, such as dairy products, broccoli, soy, sesame, figs (Matz, 2010).

• Phosphorus. This element is important for the strength and durability of tooth enamel. Also, phosphorus plays a role for proper digestion of calcium. Phosphorus can be found in fish, eggs, milk, beef and other foods (Palmer, 2007).

• Vitamin A helps tooth and enamel form. Orange fruits and vegetables like carrots and sweet potatoes are rich in vitamin A (Palmer, 2007).

• Vitamin B helps keep gum tissue healthy. Whole-grain breads and cereals and green, leafy vegetables contain vitamin B (Palmer, 2007).

• Vitamin K keeps gums healthy and controls bleeding. Dark leafy greens are good sources of vitamin K (Palmer, 2007). Vitamin D it is vital for effective digestion of both phosphorus and calcium. Body can synthesize Vitamin D itself when skin received good amounts of sunlight. Natural sources of Vitamin D include eggs, fish, and mushrooms (Palmer, 2007).

• Vitamin B6 is also important element of effective nutrition for dental health. Vitamin B6 deficiency can cause mouth dryness, as well as little wounds and cracks in our mouth. Receive good amounts of this vitamin regularly from eat potato, spinach, tomatoes, strawberries, carrot, cauliflower and other foods (Palmer, 2007).

• Vitamin C consuming a good amount of Vitamin C can guarantee a good condition of gums. Sources of Vitamin C, including oranges, lemons, onions, carrots, and sugar-beet (Palmer, 2007).

Table (3): Effects of nutritional problems on tooth development

|Period |Effects of Nutritional problems |

|Pre-eruptive period: Crown formation and mineralization within |Developing enamel and dentin are susceptible to nutritional imbalances as any other |

|the jaw |developing tissues |

|Maturation period: Teeth are erupting into oral cavity and roots|Deficiencies affect secretory or maturation stages of enamel formation |

|forming | |

| | |

| |Secretory stage deficiencies hypo plastic lesion |

| |Maturation stage deficiencies hypo mineralized defects |

|Maintenance period: Teeth are functioning in the oral cavity |Lack of constant mineralization from saliva, food, beverages and oral care products results|

| |in decreased resistance to dental caries |

Palmer, C. A. (2007): Diet and nutrition in oral health.2nd ed. Pearson prentice Hall. New Jersey. U.S.A. p278

Fluoride and dental health

Fluoride is a naturally occurring trace element present in small but widely varying amounts in soil, water, plants, and animals. Fluoride may be used systemically or topically. Systemic fluoride is ingested, absorbed, and incorporated into developing bone and teeth. Usually, delivery of system fluoride is accomplished through community water fluoridation or through fluoride supplementation. Topical fluorides are applied to erupted teeth and are not incorporated within the developing tooth structure. It serves to strengthen the surface of the developed teeth. Fluoridation of community water supplies is the most cost effective and practical public health measure for prevention of tooth decay. The practice of giving children fluoride supplements has been developed for use in areas where optimally fluoridated water supplies are not available. It is important to note that fluoride recommendations for prescription of supplements varies by age of child (Whitford, 2008).

Table (4): Fluoride Supplementation: Concentration of fluoride in drinking water in parts per million (PPM) Table:

|Age |0.6 PPM |

|Birth - 6 months |0 |0 |0 |

|6 months-3 years |0.25 |0 |0 |

|3 years-6 years |0.50 |0.25 |0 |

|6 yrs-at least 16yrs |1.0 |0.50 |0 |

Whitford, G. (2008): Georgia oral health prevention program the school nurses role in oral health.DHR.p14

Oral hygiene and dental health

Oral hygiene includes all the processes for keeping the mouth clean and healthy. Good oral hygiene is necessary for the prevention of dental caries, periodontal diseases, bad breath and other dental problems. Good oral hygiene habits will keep away most of the dental problems saving from toothaches and costly dental treatments. The interesting part is that it can be achieved by dedicating only some minutes every day to dental hygiene care. The main purpose of dental hygiene is to prevent the build-up of plaque, the sticky film of bacteria that forms on the teeth. Bacterial plaque accumulated on teeth because of poor oral hygiene is the causative factor of the major dental problems. Poor oral hygiene allows the accumulation of acid producing bacteria on the surface of the teeth. The final effect of poor oral hygiene is the loss of one or more teeth (Mayo Foundation for Medical Education and Research, 2010).

Tooth brush

Toothbrush with a small head is recommended, so that children can use it easily, and it will not cause gagging when they brush their back teeth. The handle should have the correct length and thickness. It must be easy to use and provide a firm grip. Brushes for children often have handles and heads that are brightly colored, and show cartoon characters. Brushing needs to be a fun experience (Goldstein and Peters., 2009).

Fig (7): Type of tooth brush

|[pic] | |[pic] |

|Toothbrushes for children | |Modified toothbrushes |

Goldstein, T. and Peters, R. (2009): Tooth decay causes and prevention. Simply . p5. Available on.WWW.

Fig (8): Method of teeth brushing (proper brushing techniques).

[pic]

(Mohammed. J, 2010)

Important of dental floss.

Dental Floss is the most efficient way to clean between teeth. Different types of floss are available, such as regular floss, dental tape and super floss. Floss is also available on a plastic holder, in the shape of a bow (Goldstein and Peters., 2009).

Fig (9): Dental floss

|[pic] | |[pic] |

|Superfloss | |Dental tape |

| |

|[pic] | |[pic] |

|Floss holders | |Regular floss |

Goldstein, T. and Peters, R. (2009): Tooth decay causes and prevention. Simply teeth. com. p5. Available on.WWW.

• Method of using dental flossing

o Use a 12-15inch (30-40cm) length of floss.

o Wrap the floss around your middle fingers.

o Hold the floss between the thumb and forefinger of each hand.

o Leave about 2 inches (5cm) of floss between the hands.

o Gently guide the floss across the contact point between the teeth.

o When the floss is in position between the teeth, rub it up and down a few times against each tooth surface, one after the other. Be careful not to cut gums with the floss. A sharp downward thrust of the floss will damage the gum and make it bleed (Goldstein and Peters., 2009).

Fig (10): Method of using dental flossing

|[pic] | |[pic] |

|Floss on hands | |Floss up |

|[pic] |

|Floss down |

Goldstein, T. and Peters, R. (2009): Tooth decay causes and prevention. Simply . p5. Available on.WWW.

I- Dental caries

Dental caries in children has been described as a 'pandemic' disease characterized by a high percentage of untreated carious cavities causing pain, discomfort and functional limitations. Untreated carious cavities, furthermore, have a significant impact on the general health of children and on the social and economic wellbeing of communities and are more common in developing, than in developed countries (Topaloglu et al., 2009).

Caries is a dynamic disease process, and not a static problem. Secondly, before a cavity is formed in the tooth, the caries infection can actually be reversed. Dental caries in children is typically first observed clinically as a “white spot lesion.” If the tooth surface remains intact and non-cavitated, then remineralization of the enamel is possible. If the subsurface demineralization of enamel is extensive, it eventually causes the collapse of the overlying tooth surface, resulting in a cavity (Ravel, 2004).

Risk factors for dental caries

The causes of caries are multifactorial, and the individual risk factors associated with Early Childhood Caries are therefore not necessarily causative.

• Frequent intake of carbohydrate-rich or sugary foods enables the cariogenic bacteria to maintain a low pH on the surfaces of the teeth.

• Night- time bottle feeding, or prolonged use of a sippy cup, can lead to early childhood caries. The flow of saliva is decreased during sleep, so clearance of the sugary liquid from the oral cavity is slowed down.

• The earlier that a child’s mouth is infected with Mutans streptococci, the greater the risk for future caries development.

• Children who already have one or more dental cavities are considered high risk for developing more.

• A low fluoride level on the surface of the teeth reduces the remineralization process and increases the risk for caries.

• When the saliva flow is below 0.7 ml/minute, the saliva cannot wash carbohydrates off the dental surface.

• Low socioeconomic status can reduce interest in oral hygiene and a healthy diet (Ravel, 2004).

Fig (11): Causes of dental caries[pic]

Quiroqa, S. (2005): Causes of dental caries. Arizona state university.p1. Available on.

Etiology of dental caries

• Microbial factors

Bacteria use fermentable carbohydrates for energy and the end- products of the glycolytic pathway in bacterial metabolism are acids. Sucrose is the fermentable carbohydrate most frequently implicated, but it is important to remember that the bacteria can use all fermentable carbohydrates, including cooked starches. Although any carbohydrate may cause the production of acid, it is the availability of glucose that drives bacterial metabolism to produce lactic acid rather than weaker by products such as formate, acetoacetate and alcohols. Furthermore, the amounts of fermentable carbohydrate will be used immediately (Cameron and Widmer., 2008). Mutans streptococci are a primary etiologic agent in human dental caries. Therefore an important approach toward preventing dental caries is to reduce intraoral levels of mutans streptococci (Robert et al., 2008).

• Salivary factors

The importance of saliva is often overlooked; however, it has several critical roles in the caries process. Saliva is excreted at different rates and with different constituents depending on the presence or absence of stimulatory factors. Saliva stimulated by chewing has increased calcium and phosphate ion concentrations. A gustatory effect, such as that induced by some food acids, has been shown to stimulate a high flow rate of saliva than stimulation by mechanical chewing. The major constituent of saliva is water (~99.5%), with a wide range of other inorganic and organic components, the most relevant being the salivary protein, especially the histatins, mucins and statherins, which provide: Antibacterial and antifungal and antiviral activity,Lubrication, which also assists in bolus formation,Inhibition of demineralization and stabilization of calcium and phosphate ion, which assists remineralization (Cameron and Widmer., 2008).

The relationship between salivary gland hypofunction and dental caries is related to several factors. First, the physical flow of saliva augmented by the activity of the oral musculature removes a large number of bacteria from the teeth. Second, salivary proteins and enzymes (lysozyme, lactoferrin, and lactoperoxidase) work with other salivary components to kill bacteria, interfere with bacterial replication, or interfere with the acidogenic potential of cariogenic bacteria. Third, saliva can also interfere with bacterial attachment through molecular interactions (Berkitz et al., 2010).

• Dietary factors

Most dietary sugars, carbohydrates, and starches are readily metabolized to organic acids by mutans streptococci and are termed cariogenic substrates. The frequent and prolonged oral exposure to sugars, carbohydrates, and starches facilitates dental caries activity. Stated differently, it is not how much sugar a person eats but how a person eats sugar that determines the sugar's relative cariogenic potential. Sugars contained in food products retained orally for a long time are more cariogenic than those in food products retained orally for short times (Berkowitz et al., 2008).

Fig (12): Dental caries

[pic]

Ravel, D. (2004): Management and prevention of dental caries in children.p4. Available on:

• Time

When acid challenges occur repeatedly, the eventual collapse of enough enamel crystals and subsequently rods will result in surface breakdown. This may take from months to years depending on the intensity and frequency of the acid attack. This means that in all mouths (as most mouths will contain some cariogenic bacteria) there is continual demineralization and remineralization of enamel; therefore, an individual is never free of dental caries. The process of enamel demineralization and remineralization is constantly cycling between net loss and gain of mineral. It is only when the balance leans towards net loss that clinically identifiable signs of the process become apparent. The long- term outcome of this cycling is determined by the composition an amount of plaque, sugar consumption(frequency and timing), fluoride exposure, salivary flow and quality, enamel quality and immune response (Cameron and Wilmer., 2008).

Fig (13): Etiology of dental caries

Ravel, D. (2004): Management and prevention of dental caries in children.p4. Available on:

• Cariogenecity of a food

The absolute cariogenic potential of food is influenced by many factors

A) Its fermentable carbohydrate content

B) Cariostatic factors in food- includes protein(protect against demineralization and reduce the rate of crystal dissolution), fat(shown to reduce caries in rats),calcium, phosphate and fluoride, phytates in cereals and cocoa

C) Food retention-duration of presence of carbohydrate in oral cavity influence the period of time acid remains in contact with the tooth

D) Eating pattern- sequence of food intake is very important. The acid produced by eating pears or sucrose was neutralized if they were eaten with cheese or peanuts

E) Frequency of eating is also important and is found that in between meal snacking of carbohydrate containing food increases caries prevalence such as (dried fruits, hard and soft candy, cake, cookies, pie, crackers and chips(Rao, 2008).

• Food with low cariogenic potential

-Relative high protein content such as (Milk, Meat, fish and poultry

- Moderate fat content to facilitate oral clearance such as (Fats and oils)

-A minimal concentration of fermentable carbohydrates

- Strong buffering capacity

- High mineral content

- PH>6.0

- Ability to stimulate salivary flow (Rao, 2008).

Fig (14): Dental caries

Hilton, L. (2010): Dental caries. eNotes. com, Inc. p2. Available on:

Classification of dental caries

• Pit and fissure caries:

It is the most common type of dental caries. It appears on the occlusal and buccal surfaces of molars in primary and permanent dentition. This form of caries is the most destructive because it quickly goes deeply into the dentine (Ismail, 2007).

Fig(15): Pit and fissure caries:

Thivierge, B. (2010): Tooth decay. Answer..p5. Available on:

• Smooth surface caries:

It is less common and essentially occurs on the interproximal areas of the teeth that are not self-cleaning. On occasion the cervical regions of the buccal and lingual surfaces of the teeth will become involved (Ismail, 2007).

• Cemental (root) caries:

Is nearly always exclusively found in the order population, particularly in those with gingival recession. This type of carious lesion represents considerable difficulties to the clinician because it is located in a region of the tooth where there is little tooth structure overlying the pulp (Ismail, 2007).

• Recurrent caries:

Is the term applied to caries that arises around an existing restoration. Lesions usually arise as a result of an alteration in the integrity of a restoration that results in marginal leakage (Ismail, 2007).

Figure(16): Recurrent caries

[pic]

Ismail, A. (2007): Caries diagnosis, risk assessment and management. Michigan. U.S.A. p. 1.Available on:.

Fig(17):Rampant caries.

[pic]

Thivierge, B. (2010): Tooth decay. Answer..p5. Available on:

• Rampant caries.

Rampant caries in deciduous teeth suggests prolonged contact with infant formula, milk, or juice, typically when an infant goes to bed with a bottle (baby or nursing bottle caries). Thus, bedtime bottles (Ubertalli, 2008). In some instances, caries are described in other ways that might indicate the cause. "Baby bottle caries", "early childhood caries", or "baby bottle tooth decay" is a pattern of decay found in young children with their deciduous teeth (Thivierge, 2010).

• Baby bottle tooth decay

Baby bottle tooth decay is a dental problem that frequently develops in infants that are put to bed with a bottle containing a sweet liquid. Baby bottle tooth decay is also called nursing-bottle caries and bottle-mouth syndrome. Bottles containing such liquids as milk, formula, fruit juices, sweetened drink mixes, and sugar water continuously bathe an infant's mouth with sugar during naps or at night. The bacteria in the mouth use this sugar to produce acid that destroys the child's teeth. The upper front teeth are typically the ones most severely damaged; the lower front teeth receive some protection from the tongue (Thivierge, 2010).

Symptoms of dental caries

Caries initially involves only the enamel and produces no symptoms. A cavity that invades the dentin causes pain, first when hot, cold, or sweet foods or beverages contact the involved tooth, and later with chewing or percussion. Pain can be intense and persistent when the pulp is severely involved (see Common Dental Disorders: Pulpitis) (Ubertalli, 2008).

Fig (18): Dental caries

|(B) The radiograph reveals an extensive region of demineralization |(A) A small spot of decay visible on the surface of a tooth. |

|within the dentin (arrows). |[pic] |

|[pic] | |

|(D) All decay removed. |(C) A hole is discovered on the side of the tooth at the beginning of |

|[pic] |decay removal. |

Thivierge, B. (2010): Tooth decay. Answer..p5. Available on:

Stages of tooth decay 

[pic]The pictures of tooth decay below provide an explanation of the destructive process of teeth decay, from the initial stages acid attack up to the total decay of tooth tissues (Friedman, 2009).

Fig (19): Stages of tooth decay 

|  [pic] The first indication of tooth decay is white spots on the enamel|  [pic]If the demineralization process outruns the natural |

|caused by the loss of calcium. Acids have started to dissolve and weaken|remineralization process, the lesion grows. Over time, the tooth |

|the tooth enamel (demineralization). At this stage the tooth can |enamel begins to break down beneath the surface while the surface |

|remineralize and fix the weakened area itself with the help of minerals |remains intact.  Once the decay continues and breaks through the |

|in saliva and fluoride. |surface of the enamel, the damage is permanent. |

|[pic]Left untreated, the decay will continue to dentine. When enough of |[pic]The living part of the tooth, the pulp, becomes damaged. The |

|the sub-surface enamel is eaten away, the surface collapses, forming a |bacteria invade and infect the pulp of the tooth. The blood vessels |

|cavity. The decay must be cleaned out and the cavity filled by a |and nerves may die due to the infection. Root canal therapy is |

|dentist.   |required to repair the tooth. |

|[pic]The infection can then spread to form a tooth abscess (collection |[pic]If the infection is not stopped on time and a root canal |

|of pus) around the root tip. As the infection inside the tooth's root |therapy is not carried out by the dentist, the tooth might be lost |

|canal builds up, the bone around it gets infected. The tooth pain is |or need to be extract |

|consistent, especially during the night. | |

Friedman, M. (2009): Dental caries. .p3.Available on:

Prevention of dental caries

Oral hygiene

- General care of the mouth. The best way to prevent tooth decay is to brush the teeth at least twice a day, preferably after every meal and snack, and to floss daily. Cavities develop most easily in spaces that are hard to clean. These areas include surface grooves, spaces between teeth, and the area below the gum line. Effective brushing cleans each outer tooth surface, inner tooth surface, and the horizontal chewing surfaces of the back teeth, as well as the tongue (Hilton, 2010).

Mouth care in children. Parents can easily prevent baby bottle tooth decay by not allowing a child to fall asleep with a bottle containing sweetened liquid. Bottles should be filled with plain, unsweetened water. A child should be starting to drink from a cup at around six months of age, and weaned from bottles at 12 months. After the eruption of the first tooth, parents should begin routinely wiping an infant's teeth and gums with a moist piece of gauze or soft cloth, especially before bedtime. Parents may begin brushing a child's teeth with a small, soft toothbrush at about two years of age, when most of the primary teeth have come in (Hilton, 2010).

Fluoride application

Fluoride is a natural substance that slows the destruction of enamel and helps to repair minor tooth decay damage by remineralizing tooth structure. Toothpaste, mouthwash, fluoridated public drinking water, and vitamin supplements are all possible sources of fluoride. It is important to note that bottled water and water from home purifiers often does not contain fluoride. The most common means to prevent tooth decay are to consistently brush and floss the teeth. Fluoride is usually present in toothpaste as a means to breakdown bacteria and prevents acid build-up. In some areas, fluoride is also present in the public drinking water, although this is a topic of much debate recently (Barker, 2009).

Diet

Choosing foods wisely and eating less often can lower the risk of tooth decay. Foods high in sugar and starch, especially when eaten between meals, increase the risk of cavities. The bacteria in the mouth use sugar and starch to produce the acid that destroys the enamel. The damage increases with more frequent and longer periods of eating. For better dental health, drinking water is also beneficial by rinsing food particles from the mouth (Hilton, 2010).

II- Periodontal diseases

Periodontal diseases can affect the gums and the tissue that surrounds the teeth. That consequently will result in teeth loss (Salam, 2008). Often classified according to their severity. They range from mild gingivitis, to more severe periodontitis, and finally acute necrotizing ulcerative gingivitis, which can is life threatening. Gingivitis is an inflammation of the gums surrounding the teeth. Gingivitis is one of many periodontal diseases that affect the health of the periodontium (those tissues that surround the teeth and include the gums, soft tissues, and bone) (Rich et al., 2010).

Fig(20): Normal teeth, gum and bone

Anshu, D. (2010): Gum disease (periodonititis).Chandigarh . Available on:

Types of periodontal diseases

1- Chronic gingivitis is common in children. It usually causes gum tissue to swell, turn red and bleed easily. Gingivitis is both preventable and treatable with a regular routine of brushing, flossing and professional dental care. However, if left untreated, it can eventually advance to more serious forms of periodontal disease (Salam, 2008).

2-Aggressive periodontitis can affect young people who are otherwise healthy. Localized aggressive periodontitis is found in teenagers and young adults and mainly affects the first molars and incisors. It is characterized by the severe loss of alveolar bone, and ironically, patients generally form very little dental plaque or calculus (Salam, 2008).

3- Generalized aggressive periodontitis may begin around puberty and involve the entire mouth. It is marked by inflammation of the gums and heavy accumulations of plaque and calculus. Eventually it can cause the teeth to become loose (Salam, 2008).

4- Periodontitis associated with systemic disease occurs in children and adolescents as it does in adults. Conditions that make children more susceptible to periodontal disease include type I diabetes, down syndrome (Salam, 2008).

Causes of gingivitis

Factors that can cause gingivitis can be either extrinsic (localized) or systemic. The most common extrinsic factor is the long-term effect of plaque deposits. "Plaque" is the sticky material that accumulates on the exposed portions of the teeth, and is composed of mucous, food debris, and bacteria. The bacteria release destructive byproducts, and un removed plaque may mineralize into a hard deposit called (calculus or tartar). The bacterial toxins, and calculus cause irritation and inflammation of the gingiva. Injury or any irritation to the gingiva from vigorous tooth brushing, hard food. Breathing through the mouth can also be a contributing factor to gingivitis (Heisel, 2010).

Systemic factors, such as diseases that affect the body's immune response, hormonal changes in puberty and pregnancy, nutritional deficiencies, and diabetes mellitus, may increase the gingiva sensitivity to irritation. Medications such as birth control pills and antiepileptic drugs, and ingestion of heavy metals such as lead and bismuth (found in some pharmaceuticals), may also exaggerate the inflammatory response (Heisel, 2010).

Fig (21): Gingivitis

[pic]

Gingivitis Symptoms

• Swelling, redness, pain, and bleeding of the gums are signs of gingivitis.

• The breath begins to take on a foul odor.

• The gums begin to lose their normal structure and color. The gums, which were once strong and pink, begin to recede and take on a beefy red, inflamed color (Mayo Foundation for Medical Education and Research, 2010).

• Types of Gingivitis

• Acute Gingivitis

• Chronic Gingivitis

• Acute ulcerative necrotizing gingivitis - also called (trench mouth or Vincent's disease) (MFMER, 2010).

Fig (22): Gingivitis

|[pic] | |[pic] | |[pic] |

|Puberty gingivitis | |Gingival overgrowth | |After gum surgery |

Hsieh, T., Pinskaya, Y., and Roberts, E. (2005): Assessment of orthodontic treatment outcomes: Early treatment versus late treatment. Oregon Health science, 75 (2): 162-170. Available on : Yahoo com.

Complications of gingivitis

• Severe gum disease

• Pyorrhea

• Periodontal disease

• Tooth loss (MFMER, 2010).

Prevention

Prevention from gingivitis has been compiled from various data sources and may be inaccurate or incomplete. None of these methods guarantee prevention of gingivitis. Dental hygiene, brushing teeth, flossing teeth, antiseptic mouth rinse and regular dental checkups. Good mouth and teeth care, regular dental follow-up, and treatment of underlying illnesses are also necessary for preventing gingivitis (Rich et al., 2010).

Management of gingivitis

Simple gingivitis, work with child dentist. A concerted effort between good home dental hygiene and regular dental visits should be all that is required to treat and prevent gingivitis. If gingivitis continues despite the effort to prevent it, contact doctor to investigate the possibility of an underlying illness. Gingivitis can usually be managed at home with good dental hygiene. If gingivitis turns into the most severe periodontal infection, acute necrotizing ulcerative gingivitis (ANUG), commonly referred to as trench mouth, treatment at a hospital may be required (Rich et al., 2010).

III- Dental fractures

Dental injury is a distressing event, often causing psychological as well as physical problems, since it normally involves the highly visible front teeth. In addition, the treatment of such injuries involves economic costs in both the short and the long term (Al Mannai, 2004). Trauma to teeth and orofacial structures continues as a frequent dental problem. As long as young children remain active, accidents will occur, requiring careful and conscientious care (Peng, 2009). Dental fractures involve the deeper portion of the tooth, known as the dentin. Fractures that disrupt the dentin are at risk for infection. Dental fractures that bleed disrupt the tooth pulp, which can reduce the blood supply to the tooth and results in loss of the tooth (Schueler et al., 2009).

Fig (23): Dental fracture

[pic]

(Peng, L. F. (2009): Dental fracture. . p2. Available on:

Causes of dental injuries

While most dental injuries are accidental, there are risk factors that make these accidents more likely to happen. Some of the most common are listed below.

• Playing contact sports such as rugby or boxing, or any sport that involves physical contact or moving objects such as bats and balls, can put you at risk of damaging your teeth.

• Having upper front teeth that stick out has been shown to increase your risk of damaging them.

• Being unsteady on feet (toddlers for example), or having some medical conditions (such as epilepsy) can put you at greater risk of a dental injury (Schmitt, 2008).

Fig(24): Dental fracture

|[pic] | |[pic] |

|Before | |After |

Tall, M. (2009): Dental fracture. EZ-Net . P1.Available on:

Type of dental fracture

• Accidentally biting or cutting your lip, cheek or tongue is another common occurrence and in most cases, it's not one to worry about. If it's a more serious laceration, may need to get stitches. (Medical providers like to keep oral stitches to a minimum, though, since they can interfere with eating, and in rare instances cause infection. Wash the area with warm salt water, and then apply pressure with a cold compress to try to stop the bleeding. If bleeding is severe or doesn't stop, go to the emergency room in the local hospital (Schueler et al., 2009).

• A cracked or broken tooth (fracture) is a more serious injury. If the fracture has reached the dentin or pulp, rinse child mouth with warm water, and get to dentist quickly. To give treatment to prevent infection while the pulp is still healthy. Remember, even fractures that aren't visible can worsen and require more extensive and costly dental care down the line (Koncar, 2009).

• A knocked-out tooth (avulsion) needs to be considered a dental emergency because chances for re-implanting the tooth having it take hold again in the tooth socket depend on how quickly get dental treatment. Try to see a dentist within 30 minutes of the accident can save the tooth. Front teeth make up 80 percent of all knocked-out teeth. Among adults, most teeth are dislodged playing football, baseball, or other sports. Among small children, the precarious job of learning to walk is responsible for the majority of knocked-out teeth. If child tooth is knocked out, immerse it in milk or a saline solution (never carry it dry) and take it to the dentist or emergency room (Schueler et al., 2009).

Fig(25): A cracked or broken tooth (fracture)

Ravel, D. (2003): Management of dental trauma in children.. P3. Available on:

• Displaced teeth - that is, teeth shoved out of alignment are also a serious dental condition. If child tooth is pushed inward or outward but is still attached, gently reposition it with very light finger pressure. Moisten a clean cloth and hold it in place. See the dentist within 30 minutes of the injury (Koncar, 2009).

• Upper and lower jaw injuries can occur after a traumatic event, such as a car accident or a bad fall. If child unable to close mouth normally and bring teeth together, child jaw may be broken. Jaw injuries need immediate dental and medical attention, and may be need to get child to local emergency room (Koncar, 2009).

Classification of Dental Injuries 

• Hard Tissue Fractures

Fig(26): Hard Tissue Fractures

 

|Enamal Fractures (Type I)  | |Enamel-Dentine Fractures (Type II)  |

|[pic] | |[pic] |

 

Croll, E. A. (2009): Dental trauma.Elsevier.Ltd.p7. Available on:

|Fractures Involving Pulpal Exposure (Type III) | |Crown-Root Fracture (Type IV)  |

|[pic] | |[pic] |

..

Croll, E. A. (2009): Dental trauma.Elsevier.Ltd.p7. Available on:

Complete Loss of Tooth (Type V)

|[pic]  |[pic]  |

 

Croll, E. A. (2009): Dental trauma.Elsevier.Ltd.p7. Available on:

Root Fracture (Type VI)

[pic]

Al mania, A. A. (2004): Traumatic dental injuries. Webmaster . p8. Available on:

Soft Tissue Trauma

Fig(27): Soft Tissue Trauma

|Concussion - Injury to the tooth supporting structure | |Subluxation (loosening) - Injury to the tooth |

|without abnormal loosening or displacement of the tooth, | |supporting structure with abnormal loosening, |

|but with reaction to percussion. | |but without displacement of the tooth. |

|Lateral Luxation - Displacement of the tooth in a | |Avulsion - Complete displacement of the tooth |

|direction (mesial, distal, lingual, labial) usually | |out of its socket. |

|accompanied by fracture to alveolar component. | | |

|[pic] | |[pic] |

Croll, E. A. (2009): Dental trauma.Elsevier.Ltd.p7. Available on:

Intrusive Luxation - Displacement of the tooth into the alveolar bone.

|[pic] | |[pic] |

Croll, E. A. (2009): Dental trauma.Elsevier.Ltd.p7. Available on:

Extrusive Luxation - Partial displacement of the tooth out of its socket.

|[pic] | |[pic] |

  Bottom of Form

 

American Association of Endodontists, (2010): Traumatic dental injuries. . p1. Available on:

Treatment of dental injuries

According to (Knapik et al, 2009). Treatment of dental injuries include the following:

If a tooth has been loosened or knocked out get to the dentist, will be look inside of child mouth to see if child tooth has been reimplanted properly. If child tooth hasn't yet been successfully reimplanted, the dentist will attempt to do this as soon as possible. The child will need to have tooth splinted (joined to the neighbouring teeth) in order to hold it in place while it heals. Usually a splint is a thin piece of wire, which attaches the loose tooth to those on either side of it, but there are other types of splint. If child tooth was handled carefully and reimplanted quickly, child will need to keep this on for about a week. The dentist may take some X-rays to get more information about how serious your injury is and to see if there are any pieces of broken tooth stuck in your lip, gum or tongue.

If a tooth has been chipped the treatment of a chipped tooth will depend on where child tooth has broken. Teeth have a core of blood vessels and nerves at their centre called the pulp. If child tooth is injured, the pulp can be damaged and the blood vessels may die. If a piece of child tooth has chipped off but the pulp isn't damaged, the dentist will smooth the uneven edge and replace the corner with a tooth-coloured filling. If the pulp is damaged, the dentist may need to do root canal therapy to remove the damaged blood vessels and nerves from the tooth.

If a tooth has broken roots child teeth have roots that are set in jawbones. If a root fractures (breaks), it's possible that child tooth won't look any different because the fracture is hidden by bone and gum. However, the dentist may be able to see a broken root on X-ray images. If child tooth is quite firm, the dentist may simply ask child to come back for regular X-rays and tests to make sure that the pulp remains healthy. However, if child tooth is wobbly, it will need to be splinted for a few weeks to help the fracture heal. During the weeks and months after the root fracture, if the dentist finds that the pulp has been damaged and isn't going to recover, may recommend that child have root canal therapy to save the tooth.

Prevention of dental injuries

If regularly play a sport that puts any risk (eg rugby, boxing, cricket, and hockey) may wish to consider getting a mouth guard. This will offer some protection and can reduce the likelihood of getting an injury. Mouth guards are usually made of rubber and form a cover that goes over your teeth and gums (Knapik, et al., 2009).

IV- Dental Erosion

Tooth wear is becoming more common, both in children, and in adults who are now keeping their teeth for very much longer. There are several ways in which teeth can wear away but one of them is known as dental erosion and this is due to a chemical process which literally dissolves the surface of the teeth away rather like a sugar lump dissolving in hot tea. Substances that cause this chemical dissolution are usually acids and can come from a variety of source (Friedman, 2009). Dental erosion is a permanent loss of all or part of a tooth due to the gradual chemical breakdown of the tooth. This breakdown is triggered by the introduction of some type of acid to the surface of the tooth (Tatum, 2010).

Fig(28): Tooth erosion

[pic]

Byrne, E. (2010): Dental erosion. .p1.Available on:

Causes of tooth erosion

• Extrinsic factor (From outside the body)

[pic]Frequent consumption of acidic foods and drinks is the main cause of tooth enamel loss. Fruit juices and fresh fruits are considered as healthy foods, their over consumption is not the best option for teeth because they are too acidic (very low pH). Most of the popular carbonated drinks, soft drinks, sports drinks and diet drinks are also very acidic. Common extrinsic dietary acids include citric acid, phosphoric acid, ascorbic acid, and carbonic acid. Some medicines are acidic and, therefore, erosive. They can cause dental erosion on direct contact with the teeth when the medication is chewed or held in the mouth prior to swallowing (Friedman, 2009).

Intrinsic factor (From inside the body)

[pic]Gastro esophageal reflux disease or acid reflux, in which stomach acids come up into the esophagus and mouth, can cause severe tooth erosion. Eating disorders that cause frequent vomiting are also responsible for tooth enamel loss caused by the gastric acids. Low salivary flow rate is a significant risk factor for dental erosion due to reduced pH buffering capacity (its ability to neutralize changes in mouth’s pH) (Friedman, 2009).

Early Symptoms of Tooth Erosion

According to (Tatum, 2010). Symptoms of Tooth Erosion include the following:

1. [pic]Teeth Discoloration Since the dentin of the tooth is exposed during tooth erosion, discoloration or yellowing of the teeth can occur. The more dentin that is exposed, the more yellow the teeth will become.

2. Tooth Sensitivity Sensitive teeth are very common symptoms of teeth erosion because the enamel that protects the teeth wears away, leaving exposed the dentin (the softer, sensitive part of the tooth).

3. Rounded/Shorter Teeth – Teeth with dental erosion have usually a rounded look. If the tooth enamel loss is extensive teeth might also look shorter.

4. Transparency - The tips of the front teeth might look transparent.

[pic]Advanced Symptoms of Tooth Erosion

5. Cracking - If tooth erosion continues, the edges of the teeth can start to crack and have a rough feeling.

6. Pulp exposure in deciduous teeth

7. Tooth decay – teeth affected by dental erosion are more likely to suffer from tooth decay

Fig(29): Tooth erosion

[pic][pic]

Cate,T. J. and Imfeld, T. (2007): Dental erosion. Kosmix .p1.Available on:

Prevention of dental erosion

1. Decrease the consumption of acidic foods and/or drinks, both in quantity and frequency. Replace carbonated drinks with water, milk or un-sweetened coffee and tea, especially between meals.

2. Use a straw when drinking carbonated beverages or fruit juices, which are very acidic (at least to limit contact of acids with the front teeth).

3. After eating or drinking acidic foods or beverages, rinse your mouth with fresh water so that the acid is diluted and easier neutralized.

4. Chewing sugar-free gum can help reduce dry mouth and increase the saliva flow, allowing it to neutralize acids and help teeth to remineralize.

5. Should be brush child teeth twice a day, with a soft toothbrush using fluoride toothpaste. Fluoride helps the remineralization of the tooth enamel and it is necessary for preventing tooth erosion.

6. Follow up the dentist’s instructions in order to prevent further tooth enamel loss (Byrne, 2010).

Role of school nurse

School nurse a specialized practice of professional nursing that advances the well-being, academic success, and lifelong achievement of students. To that end, school nurses facilitate positive student responses to normal development; promote health and safety; intervene with actual and potential health problems; provide case management services; and actively collaborate with others to build student and family capacity for adaptation, self-management, self-advocacy, and learning (Jones, 2008).

School nurse's role

The school nurse provides direct care to students. Provides care for injuries and acute illness for all students. Assess the student's health status, identify health problems that may create a barrier to educational progress, and develop a health care plan for management of the problems in the school setting. School nurse assesses the overall system of care and develops a plan for ensuring that health needs are met. Provides screening and referral for health conditions. Promotes a healthy school environment and provide the physical and emotional safety of the school community by monitoring immunizations, ensuring appropriate exclusion for infectious illnesses, and reporting communicable diseases as required by law (King and Eckstein., 2006).

The school nurse provides health education by providing health information to students and groups of students through health education, science, and other classes. Health education topics may include nutrition, exercise, oral health and prevention of infectious diseases (Jones, 2008).

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