A Physician's Guide to Identifying Pediatric Dental Decay and Common Oral Pathology
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For most children the entry point into the healthcare system is through primary care physicians and pediatricians. These individuals are experts at screening and diagnosing disease, and are thoroughly trained to ascertain when physical findings deviate from normal. Although they are responsible for surveillance of the full spectrum of human disease, a provider can only be expected to perceive abnormalities they have been trained to recognize. Oral health is just one of the many areas that medical providers are responsible to evaluate, but because clinicians often receive so little training in this area it is likely that they will only be able to diagnose very obvious deviations from the healthy dental state.
Like many other areas of a physical examination, the oral health exam is visual. The clinician must use a trained sense of sight to evaluate a young child’s mouth. If the clinician is not calibrated to recognize the various states of disease and health, it is quite likely that they will not diagnose mild forms of dental caries. This is critical, because when caries is mild, preventive interventions are most capable of stopping its progression. When decay progresses past the point of mild disease it often must be surgically corrected with a dental restoration. To address the specific need for a sophisticated tutorial on the visual presentation of Early Childhood Caries (ECC) and common pediatric oral pathology this visual guide was developed.
Areas of Emphasis:
-Positioning for the oral examination
One of the most important aspects of the oral exam is preparation and positioning of the patient. The tutorial demonstrates the knee-to-knee examination position. This technique places the child at ease, and is recommended as an excellent method for visualizing the mouths of very young children.
-White spot lesion identification
The tutorial focuses on the recognition of the mild or incipient stage of dental decay: the white spot lesion. The white spot lesion forms when acid from dental plaque has caused enamel to demineralize. Removal of minerals from the enamel causes the tooth surface to appear chalky and white. This change is subtle, and often is not recognized when the tooth is wet with saliva. For this reason, it becomes important to dry the teeth with gauze prior to visual inspection. Only then can this subtle lesion be best appreciated. Photographs of wet and dry teeth are be presented to highlight this subtle but important concept. Recognition of this lesion is critical because therapeutic modalities like fluoride varnish and antimicrobials are optimally effective at this stage of the caries process. White spot lesions that are treated at this stage can be arrested before they become frank decay. If the lesion is not recognized and treated it will cavitate-a state which most often must be treated using restorative dentistry.
-Typical patterns of decay
As with other types of pathology, ECC has a variable presentation. For this reason the tutorial will focus on typical patterns of decay and give numerous case examples of each type. Photographic examples will include: the nursing habit-associated pattern (maxillary anterior pattern), Molar pit pattern, and the Molar proximal pattern. It is important that physicians understand variations in presentation and examine patients in a fashion that will enable them to recognize it. For example: the maxillary anterior pattern of decay can easily be missed when it is in the early stages because decay initially forms on the posterior surface of the maxillary incisor. Unless the clinician turns their neck to visualize this area or uses a mirror they will miss diagnosing large lesions. The tutorial emphasizes the importance of understanding each pattern and examining in a fashion that will enable diagnosis of difficult-to-see lesions.
-Common pediatric oral pathology
Several common forms of pediatric oral pathology are presented. These range from developmental anomalies of the dentition to soft tissue lesions of the newborn. Recognition of these is important, and understanding of the common presentation will better equip the clinician to recognize deviations from normal.
Fluoride varnish application and occlusal sealants have been shown to dramatically reduce caries incidence. Photographs demonstrating these interventions are shown to familiarize the practitioner with the modalities and encourage partnership with dentists to optimally care for children’s oral health.
The most common disease of childhood is dental caries.1 The majority of children do not receive dental care early in life, but by the age of 3 more than 30 percent of children from lower socioeconomic groups have dental decay.2 Although the majority of these children may not have seen a dentist, most have seen a physician. According to well-child visit schedules, physicians may see children up to 11 times before the age of 3.1 Recognizing this fact, The American Academy of Pediatrics (AAP), The American Academy of Family Physicians (AAFP), and the American Academy of Pediatric Dentistry (AAPD) now recommend that children receive a oral health screening by a dental or medical provider by age 1. If dental caries is diagnosed early in children, it can be treated conservatively using Fluoride varnish, antimicrobials, hygiene, dietary modification, and simple restorative dental techniques. Utilizing these preventive practices can help avoid the pain, infection, and cost that results from dental caries. Costs are typically several thousand dollars when general anesthesia services are required to restore late-stage decay.3
It has recently been reported that approximately 70% of medical students receive less than 5 hrs of oral health training, with 10% receiving no training at all.4 In order for physicians to effectively screen young children they must be able to recognize the signs of early dental disease. If physicians are not educated to see the earliest signs of disease, it is likely that they will only intervene or refer to dental providers when the disease has progressed to a degree that it is blatantly obvious. At that point, preventive measures will be insufficient and the child will almost certainly require restorative dental care. A training module that demonstrates visually the various stages and presentations of dental caries in young children will allow medical providers to have the knowledge and virtual experience to make a diagnosis of caries at a time when preventive practices will be most likely to succeed.
- Douglass J, Douglass A, Silk A. A Practical Guide to Infant Oral Health: American Family Physician; 2004. p. 2113-20.
- Tang JM, Altman DS, Robertson DC, et al. Dental caries prevalence and treatment levels in Arizona preschool children. Public Health Rep 1997;112(4):319-29; 30-1.
- Health WSDoP. Evidence-based prevention improves health and is cost effective.
- Ferullo A, Silk H, Savageau JA. Teaching oral health in U.S. medical schools: results of a national survey. Acad Med 2011;86(2):226-30.
- Edelstein BL, Douglass CW. Dispelling the myth that 50 percent of U.S. schoolchildren have never had a cavity. Public Health Rep 1995;110(5):522-30; discussion 21, 31-3.
Nelson T. A physician's guide to identifying pediatric dental decay and common oral pathology. MedEdPORTAL Publications. 2012;8:9223. http://dx.doi.org/10.15766/mep_2374-8265.9223
- To learn proper placement of the child patient for an oral exam.
- To become familiar with the appearance of white spot lesions- the earliest sign of dental caries.
- To learn to diagnose frank dental caries in children <6 years of age.
- To be able to differentiate normal tooth variants from the disease state.
- To recognize common pediatric oral pathology.
- To understand therapeutic modalities physicians and dentists can use to treat dental decay.
- Oral Health, Pediatric Dentistry, Dental Caries, Fluoride Varnishes, Dental Sealants, Pits and Fissure Sealants, Oral Pathology, Building Oral Health Capacity (BOHC) Collection
This information is made available under the Creative Commons license.
Authors & Co-Authors
Travis Nelson, MD
University of Washington School of Medicine
Sponsorship or Funding Source
This publication is sponsored in part by funding from the Health Resources and Services Administration/Maternal Child Health Bureau grant #U44MC20223.