In children, odontogenic infections may involve more than 1 tooth and usually are due to carious lesions, periodontal problems, or a history of trauma. Untreated odontogenic infections can lead to pain, abscess, and cellulitis. As a consequence of this, children are prone to dehydration—especially if they are not eating well due to pain and malaise. Prompt treatment of the source of infection is important in order to control pain and prevent the spread of infection.
With infections of the upper portion of the face, patients usually complain of facial pain, fever, and inability to eat or drink. Care must be taken to rule out sinusitis, as symptoms may mimic an odontogenic infection. Occasionally in upper face infections, it may be difficult to find the true cause. Infections of the lower face usually involve pain, swelling, and trismus. They frequently are associated with teeth, skin, local lymph nodes, and salivary glands. Swelling of the lower face more commonly has been associated with dental infection.
Most odontogenic infections can be managed with pulp therapy, extraction, or incision and drainage. Infections of odontogenic origin with systemic manifestations (e.g., elevated temperature of 102° to 104°F, facial cellulitis, difficulty in breathing or swallowing, fatigue, nausea) require antibiotic therapy. Severe but rare complications of odontogenic infections include cavernous sinus thrombosis and Ludwig's angina. These conditions can be life threatening and may require immediate hospitalization with intravenous antibiotics, incision and drainage, and referral/consultation with an oral and maxillofacial surgeon.
Extraction of Erupted Teeth
Maxillary and Mandibular Anterior Teeth
Most primary and permanent maxillary and mandibular central incisors, lateral incisors, and canines have conical single roots. In most cases, extraction of anterior teeth is accomplished with a rotational movement, due to their single root anatomies. However, there have been reported cases of accessory roots observed in primary canines. Radiographic examination is helpful to identify differences in root anatomy prior to extraction. Care should be taken to avoid placing any force on adjacent teeth that could become luxated or dislodged easily due to their root anatomy.
Maxillary and Mandibular Molars
Primary molars have roots that are smaller in diameter and more divergent than permanent molars. Root fracture in primary molars is not uncommon due to these characteristics as well as the potential weakening of the roots caused by the eruption of their permanent successors. To avoid inadvertent extraction or dislocation of or trauma to the permanent successor, careful evaluation of the relationship of the primary roots to the developing succedaneous tooth should be completed. Primary molars with roots encircling the successor's crown may need to be sectioned to protect the permanent tooth's location.
Molar extractions are accomplished by using slow continuous palatal/lingual and buccal force allowing for the expansion of the alveolar bone to accommodate the divergent roots and reduce the risk of root fracture. When extracting mandibular molars, care should be taken to support the mandible to protect the temporomandibular joints from injury.
Fractured Primary Tooth Roots
The dilemma to consider when treating a fractured primary tooth root is that removing the root tip may cause damage to the succedaneous tooth, while leaving the root tip may increase the chance for postoperative infection and delay eruption of the permanent successor. Radiographs can assist in the decision process. The literature suggests that if the fractured root tip can be removed easily, it should be removed. If the root tip is very small, located deep in the socket, situated in close proximity to the permanent successor, or unable to be retrieved after several attempts, it is best left to be resorbed.
Unerupted and Impacted Teeth
Permanent maxillary canines are second to third molars in frequency of impaction. Early detection of an ectopically erupting canine through visual inspection, palpation, and radiographic examination is important to minimize such an occurrence. Panoramic and periapical films are useful in locating potentially ectopic canines. Routine evaluation of patients in mid-mixed dentition should involve identifying signs such as lack of canine bulges and asymmetry in pattern of exfoliation. Eruption of canines and abnormal angulation or ectopic eruption of developing permanent cuspids can be detected with a radiograph. When the cusp tip of the permanent canine is just mesial to or overlaying the distal half of the long axis of the root of the permanent lateral incisor, canine palatal impaction usually occurs. Extraction of the primary canines is the treatment of choice when malformation or ankylosis is present, when the risk of resorption of the adjacent tooth is evident, or when trying to correct palatally impacted canines, provided there are normal space conditions and no incisor resorption. One study showed that 78% of ectopically erupting permanent canines normalized within 12 months after removal of the primary canines; 64% normalized when the starting canine position overlapped the lateral incisor by more than half of the root and 91% normalized when the starting canine position overlapped the lateral incisor by less than half of the root. If no improvement in canine position occurs in a year, surgical and/or orthodontic treatment were suggested. Although a Cochrane review yielded a lack of randomized controlled clinical studies to support extraction of primary canines to facilitate eruption of ectopic permanent maxillary canines, the literature suggests that this can be considered to minimize complications resulting from impacted canines. Consultation between the practitioner and an orthodontist may be useful in the final treatment decision.
Panoramic or periapical radiographic examination is indicated in late adolescence to assess the presence, position, and development of third molars. The American Association of Oral and Maxillofacial Surgeons (AAOMS) recommends that a decision to remove or retain third molars should be made before the middle of the third decade. Little controversy surrounds their removal when pathology (e.g., cysts or tumors, caries, infection, pericoronitis, periodontal disease, detrimental changes of adjacent teeth or bone) is associated and/or the tooth is malpositioned or nonfunctional (i.e., an unopposed tooth). A systematic review of research literature from 1984 to 1999 concluded there is no reliable evidence to support the prophylactic removal of disease-free impacted third molars. Although prophylactic removal of all impacted or unerupted disease-free third molars is not indicated, consideration should be given to removal by the third decade when there is a high probability of disease or pathology and/or the risks associated with early removal are less than the risks of later removal. Removing the third molars prior to complete root formation may be surgically prudent. AAOMS performed an age-related third molar study among board-certified oral and maxillofacial surgeons in 2001 and concluded that third molar removal in adults is safe with minimal complications and negative effects on the patient's quality of life. The report showed that mandibular third molars exhibited more pathology or abnormalities. All intraoperative complications (e.g., nerve injury, unexpected hemorrhage, unplanned transfusion or parenteral drugs, compromised airway, fracture, other injuries to adjacent teeth/structures) occurred at a frequency less than 1%. Excluding alveolar osteitis, postoperative complications (e.g., paresthesia, infection, trismus, hemorrhage) were similarly low. Factors that increase the risk for complications (e.g., coexisting systemic conditions, location of peripheral nerves, history of temporomandibular joint disease, presence of cysts or tumors) and position and inclination of the molar in question should be assessed. The age of the patient is only a secondary consideration. Referral to an oral and maxillofacial surgeon for consultation and subsequent treatment may be indicated. When a decision is made to retain impacted third molars, they should be monitored for change in position and/or development of pathology, which may necessitate later removal.
Supernumerary teeth and hyperdontia are terms to describe an excess in tooth number. Supernumerary teeth are thought to be related to disturbances in the initiation and proliferation stages of dental development. Although some supernumerary teeth may be syndrome associated (e.g., cleidocranial dysplasia) or of familial inheritance pattern, most supernumerary teeth occur as isolated events.
Supernumerary teeth can occur in either the primary or permanent dentition. In 33% of the cases, a supernumerary tooth in the primary dentition is followed by the supernumerary tooth complement in the permanent dentition. Reports in incidence of supernumerary teeth can be as high as 3%, with the permanent dentition being affected 5 times more frequently than the primary dentition and males being affected twice as frequently as females.
Supernumerary teeth will occur 10 times more often in the maxillary arch versus the mandibular arch. Approximately 90% of all single tooth supernumerary teeth are found in the maxillary arch, with a strong predilection to the anterior region. The maxillary anterior midline is the most common site, in which case the supernumerary tooth is known as a mesiodens; the second most common site is the maxillary molar area, with the tooth known as a paramolar. A mesiodens can be suspected if there is an asymmetric eruption pattern of the maxillary incisors, delayed eruption of the maxillary incisors with or without any over-retained primary incisors, or ectopic eruption of a maxillary incisor. The diagnosis of a mesiodens can be confirmed with radiographs, including occlusal, periapical, or panoramic films, or computed tomography. Three-dimensional information needed to determine the location of the mesiodens or impacted tooth can be obtained by taking 2 periapical radiographs using either 2 projections taken at right angles to one another or the tube shift technique (buccal object rule or Clark's rule) or by cone beam computed tomography.
Complications of supernumerary teeth can include delayed and/or lack of eruption of the permanent tooth, crowding, resorption of adjacent teeth, dentigerous cyst formation, pericoronal space ossification, and crown resorption. Early diagnosis and appropriately timed treatment are important in the prevention and avoidance of these complications.
Because only 25% of all mesiodens erupt spontaneously, surgical management often is necessary. A mesiodens that is conical in shape and is not inverted has a better chance for eruption than a mesiodens that is tubercular in shape and is inverted. The treatment objective for a nonerupting permanent mesiodens is to minimize eruption problems for the permanent incisors. Surgical management will vary depending on the size, shape, and number of supernumeraries and the patient's dental development. The treatment objective for a nonerupting primary mesiodens differs in that the removal of these teeth usually is not recommended, as the surgical intervention may disrupt or damage the underlying developing permanent teeth. Erupted primary tooth mesiodens typically are left to shed normally upon the eruption of the permanent dentition.
Extraction of an unerupted primary or permanent mesiodens is recommended during the mixed dentition to allow the normal eruptive force of the permanent incisor to bring itself into the oral cavity. Waiting until the adjacent incisors have at least two-thirds root development will present less risk to the developing teeth but still allow spontaneous eruption of the incisors. In 75% of the cases, extraction of the mesiodens during the mixed dentition results in spontaneous eruption and alignment of the adjacent teeth. If the adjacent teeth do not erupt within 6 to 12 months, surgical exposure and orthodontic treatment may be necessary to aid their eruption. The diagnosing dentist may consider a multidisciplinary approach when treating difficult or complex cases.
Pediatric Oral Pathology
Lesions of the Newborn
Oral pathologies occurring in newborn children include Epstein's pearls, dental lamina cysts, Bohn's nodules, and congenital epulis. Epstein's pearls are common and found in about 75% to 80% of newborns. They occur in the median palatal raphe area, as a result of trapped epithelial remnants along the line of fusion of the palatal halves. Dental lamina cysts, found on the crests of the dental ridges, most commonly are seen bilaterally in the region of the first primary molars. They result from remnants of the dental lamina. Bohn's nodules are remnants of salivary gland epithelium and usually are found on the buccal and lingual aspects of the ridge, away from the midline. Epstein's pearls, Bohn's nodules, and dental lamina cysts typically present as asymptomatic 1 mm to 3 mm nodules or papules. They are smooth, whitish in appearance, and filled with keratin. No treatment is required, as these cysts usually disappear during the first 3 months of life.
Congenital epulis of the newborn, also known as granular cell tumor or Neumann's tumor, is a rare benign tumor seen only in newborns. This lesion is typically a protuberant mass arising from the gingival mucosa. It is most often found on the anterior maxillary ridge. Patients typically present with feeding and/or respiratory problems. Congenital epulis has a marked predilection for females at 8:1 to 10:1. Treatment normally consists of surgical excision. The newborn usually heals well, and no future complications or treatment should be expected.
Eruption Cyst (Eruption Hematoma)
The eruption cyst is a soft tissue cyst that results from a separation of the dental follicle from the crown of an erupting tooth. Fluid accumulation occurs within this created follicular space. Eruption cysts most commonly are found in the mandibular molar region. Color of these lesions can range from normal to blue-black or brown, depending on the amount of blood in the cystic fluid. The blood is secondary to trauma. If trauma is intense, these blood filled lesions sometimes are referred to as eruption hematomas.
Because the tooth erupts through the lesion, no treatment is necessary. If the cyst does not rupture spontaneously or the lesion becomes infected, the roof of the cyst may be opened surgically.
The mucocele is a common lesion in children and adolescents resulting from the rupture of a minor salivary gland excretory duct, with subsequent leakage of mucin into the surrounding connective tissues that later may be surrounded in a fibrous capsule. Most mucoceles are well-circumscribed bluish translucent fluctuant swellings (although deeper and long-standing lesions may range from normal in color to having a whitish keratinized surface) that are firm to palpation. Local mechanical trauma to the minor salivary gland is often the cause of rupture. Mucoceles most frequently are observed on the lower lip, usually lateral to the midline. Mucoceles also can be found on the buccal mucosa, ventral surface of the tongue, retromolar region, and floor of the mouth (ranula).
Superficial mucoceles and some other mucoceles are short-lived lesions that burst spontaneously, leaving shallow ulcers that heal within a few days. Many lesions, however, require treatment to minimize the risk of recurrence.
A prominent maxillary frenum in children, although a common finding, is often a concern, especially when associated with a diastema. A comparison of attached frena with and without diastemas found no correlation between the height of the frenum attachment and diastema presence and width. Treatment is suggested when the attachment exerts a traumatic force on the gingiva causing the papilla to blanch when the upper lip is pulled or if it causes a diastema to remain after eruption of the permanent canines. Interference with oral hygiene measures, esthetics, and psychological reasons are contributing factors that relate to treatment of the maxillary frenum. Treatment options can include orthodontics, restorative dentistry, surgery, or a combination of these. When a diastema is present, the objectives for treatment involve managing both the diastems or permanent teeth and its cause while maintaining stable results in the future. It is recommended that treatment be delayed until the permanent incisors and cuspids have erupted and the diastema has had an opportunity to close naturally. If orthodontic treatment is indicated, the frenectomy (complete excision [i.e., removal of the whole frenulum]) should be performed only after the diastema is closed as much as possible to achieve stable results. When indicated, a maxillary frenectomy is a fairly simple procedure and can be performed in the office setting.
Mandibular Labial Frenum
A high frenum can sometimes present on the labial aspect of the mandibular ridge. This is most often seen in the central incisor area and frequently occurs in individuals where the vestibule is shallow. The mandibular anterior frenum, as it is known, occasionally inserts into the free or marginal gingival tissue. Movements of the lower lip cause the frenum to pull on the fibers inserting into the free marginal tissue, which, in turn, can lead to food and plaque accumulation. Early treatment can be considered to prevent subsequent inflammation, recession, pocket formation, and possible loss of the alveolar bone and/or tooth. However, if factors causing gingival/periodontal inflammation are controlled, the degree of recession and need for treatment decreases.
Mandibular Lingual Frenum/Ankyloglossia
When indicated, frenuloplasty (various methods to release the tongue tie and correct the anatomic situation) or frenectomy (simple cutting of the frenulum) may be a successful approach to facilitate breastfeeding; however, there is a need for evidence-based research to determine indications for treatment. This indicates that there is a need to standardize a classification system and justify parameters for surgical correction of ankyloglossia among neonates.
Limitations in tongue mobility and speech pathology have been associated with ankyloglossia. There has been varied opinion among health care professionals regarding the correlation between ankyloglossia and speech disorders. Frenuloplasty or frenectomy in conjunction with speech therapy can be a treatment option to improve tongue mobility and speech. Further evidence is needed to determine the benefit of surgical correction of ankyloglossia in resolving speech pathology.
There is limited evidence to show an association between ankyloglossia and Class III malocclusion. Speculations have been made that the abnormal tongue position may affect skeletal development. Although there are no clear recommendations in the literature, a complete orthodontic evaluation, diagnosis, and treatment plan are necessary prior to any surgical intervention.
Reports also have been made regarding the association between frenal attachment and gingival recession; further clinical evidence, however, is warranted to show a clear relationship between these 2 factors. Elimination of plaque-induced gingival inflammation can minimize gingival recession without any surgical intervention.
The significance and management of ankyloglossia are very controversial due to the lack of evidence-based studies to support frenotomy, frenectomy, and frenuloplasty among children and adults affected by ankyloglossia. Studies have shown a difference in treatment recommendations among speech pathologists, pediatricians, otolaryngologists, lactation specialists, surgeons, and dental specialists. Most professionals, however, will agree that there are certain indications for these procedures. A short lingual frenum can inhibit tongue movement and create deglutition problems. If there is no improvement in breastfeeding for a child with ankyloglossia after non-surgical intervention, frenectomy may be indicated. Although there is limited evidence in the literature to promote the timing, indication, and type of surgical intervention, frenectomy for functional limitations due to severe ankyloglossia should be considered on an individual basis. If evaluation shows that function may be improved by surgery, treatment should be considered.
Frenectomy involves surgical incision, establishing hemostasis, and suturing of the wound. Dressing placement or the use of antibiotics is not necessary. Recommendations include maintaining a soft diet, regular oral hygiene, and analgesics as needed. Although there is minimal evidence-based research available, the use of laser technology and electrosurgery for frenectomies have demonstrated a shorter operative working time, the ability to control bleeding quickly, reduced pain and discomfort, fewer postoperative complications (e.g., pain, swelling, infection), and no need for suture removal, as well as increasing patient acceptance. These procedures require skilled technique and patient management.
Natal and Neonatal Teeth
Natal and neonatal teeth can present a challenge when deciding on appropriate treatment. Natal teeth have been defined as those teeth present at birth, and neonatal teeth are those that erupt during the first 30 days of life. The occurrence of natal and neonatal teeth is rare; the incidence varies from 1:1,000 to 1:30,000. The teeth most often affected are the mandibular primary incisors. In most cases, anterior natal and neonatal teeth are part of the normal complement of the dentition. Natal or neonatal molars have been identified in the posterior region and may be associated with systemic conditions or syndromes (e.g., Pfieffer syndrome, histiocytosis X). Although many theories exist as to why the teeth erupt prematurely, currently no studies confirm a causal relationship with any of the proposed theories. The superficial position of the tooth germ associated with a hereditary factor seems to be the most accepted possibility.
If the tooth is not excessively mobile or causing feeding problems, it should be preserved and maintained in a healthy condition if at all possible. Close monitoring is indicated to ensure that the tooth remains stable.
Riga-Fede disease is a condition caused by the natal or neonatal tooth rubbing the ventral surface of the tongue during feeding leading to ulceration. Failure to diagnose and properly treat this lesion can result in dehydration and inadequate nutrient intake for the infant. Treatment should be conservative and focus on creating round, smooth incisal edges. If conservative treatment does not correct the condition, extraction is the treatment of choice.
An important consideration when deciding to extract a natal or neonatal tooth is the potential for hemorrhage. Extraction is contraindicated in newborns due to risk of hemorrhage. Unless the child is at least 10 days old, consultation with the pediatrician regarding adequate hemostasis may be indicated prior to extraction of the tooth.