1 What is the typical age at which an infant acquires the full complement of primary teeth?

The second primary molars typically erupt at about 22 months of age; most children have the full complement of 20 primary teeth around their second birthday.

2 Which are the first permanent teeth to erupt? Which teeth come next?

The first permanent teeth to erupt are usually the first permanent molars (“6-year” molars), followed by the mandibular central incisors, maxillary central incisors, lateral incisors, cuspids, and bicuspids. The mixed dentition phase concludes at about age 12 years with the eruption of the second permanent (“12-year”) molars, but the adult complement of 32 teeth is not achieved until the eruption of the third molars (“wisdom” teeth) in late adolescence (Fig. 43-1).

Figure 43-1 Primary and secondary tooth eruptions.

From Nazif MM, et al: Oral disorders. In Zitelli BJ, Davis HW [eds]: Atlas of Pediatric Physical Diagnosis, 2nd ed. New York, Harcourt, 1992, Fig. 20.9.

3 What are Epstein’s pearls? How do they differ from Bohn’s nodules and dental laminal cysts?

Cystic lesions in the oral cavity of newborns are quite common, occurring in 80% of normal newborns. They are generally small, and superficial, and are caused by entrapment of bits of embryologic tissue within dental epithelium.

Nelson LP, Shusterman S: Dental emergencies. In Fleisher GR, Ludwig S (eds): Pediatric Emergency Medicine, 4th ed. Philadelphia, Lippincott Williams & Wilkins, 2006.

4 Does teething cause fever?

Teething has been blamed for a number of symptoms in infants throughout time, ranging from fever, congestion, diarrhea, and rashes to seizures and death. A recent prospective descriptive study of 425 tooth eruptions in 125 children looked at parental reports of 18 “teething symptoms” daily for 8 months. Symptoms that were statistically linked to the eruption of a tooth included mild temperature elevation (temperature < 38.8° C), biting, drooling, facial rash, and decreased appetite for solids. Congestion, cough, vomiting, diarrhea, and temperature > 38.8° C were not associated with teething.

Macknin ML, Piedmonte M, Jacobs J, Skibinski C: Symptoms associated with infant teething: A prospective study. Pediatrics 105:747–752, 2000.

5 An 8-year-old presents with a blue-black cystic lesion over an erupting tooth What is the cause?

An eruption cyst is a nontender, fluid-filled cyst that sometimes forms over the crown of an erupting tooth. Occasionally, these cysts will fill with blood, creating the eruption hematoma described above. These cysts or hematomas are benign and self-limiting conditions that resolve when the tooth erupts.

6 What are the three main “ingredients” in the development of dental caries?

Dental caries is one of the most common disease processes in children, affecting about 5% of all children in the first few years of life, with much higher percentages in indigent children. The disease of dental caries is multifactorial in origin, requiring a susceptible host (genetic predisposition), a cariogenic diet (sticky sweets), and bacteria (most commonly Streptococcus mutans).

Tinanoff N, Kanellis MJ, Vargas CM: Current understanding of the epidemiology, mechanisms, and prevention of dental caries in preschool children. Pediatr Dent 24:543–551, 2002.

7 Are dental caries contagious?

In a sense, yes. S. mutans has been shown to be transmitted both vertically and horizontally and can colonize the mouths of infants even prior to the eruption of teeth. Thus, practices such as the “premoistening” of a pacifier with maternal saliva before insertion into the infant’s mouth should be strongly discouraged.

Berkowitz RJ: Mutans streptococci: Acquisition and transmission. Pediatr Dent 28:106–109, 2006.

8 Why is a dentoalveolar abscess more likely to “point” toward the buccal aspect of the gingiva than the lingual aspect?

Dentoalveolar abscesses are a common cause of facial cellulitis based on the anatomy of the alveolar bone. The outer buccal aspect of the bone is much thinner than the inner lingual aspect; hence the path of least resistance for drainage is through the fascial planes of the cheek and face.

9 What are the indications for hospital admission for a patient with a dental abscess?

The majority of dental abscesses can be managed on an outpatient basis with oral antibiotics and close dental follow-up for drainage or extraction of the affected tooth. Facial cellulitis resulting from an abscessed tooth can be managed with outpatient antibiotics also, unless the orbit is involved or the amount of swelling and pain compromises the airway or the ability to take fluids. Children who are toxic-appearing, highly febrile, or lacking appropriate social support for follow-up should be admitted.

Nelson LP, Shusterman S: Dental emergencies. In Fleisher GR, Ludwig S (eds): Pediatric Emergency Medicine, 4th ed. Philadelphia, Lippincott Williams & Wilkins, 2006.

10 What are the most common complications of wisdom tooth extraction?

Extraction of the third molars, or “wisdom teeth,” is a common procedure in late adolescence and early adulthood. Complications resulting in a visit to the emergency department may include hemorrhage, infection, or alveolar osteitis (“dry socket”). The extraction site may normally ooze for 8–12 hours after the procedure; persistent oozing beyond 12 hours or frank bleeding at any point may require a coagulation profile. Most bleeding will be controlled with pressure, best achieved by biting on gauze sponges for 15–30 minutes. Moistened tea bags placed over the socket may facilitate clotting, based on the coagulating properties of tannic acid. If pressure fails to control the bleeding, the socket may be packed with Gelfoam or closed with sutures. Infection of the extraction socket is rare, but should be suspected in the presence of fever, swelling, or purulent exudate from the extraction site. Penicillin and pain control are the mainstays of treatment. Alveolar osteitis is a painful inflammatory process caused by disintegration of the clot in the tooth socket, typically occurring 3 days after extraction. Treatment consists of debridement and packing of the socket.

11 What are the complications of oral piercings? Can they be life-threatening?

Complications of oral (lip and tongue) piercing include:

Potentially life-threatening complications include disseminated infection, such as mediastinitis and endocarditis, and hemorrhage, especially in patients with an underlying predisposition.

Larzo MR, Grimm Poe S: Adverse consequences of tattoos and body piercings. Pediatr Ann 35:187–192, 2006.

12 What is meant by the term geographic tongue?

Geographic tongue, or benign migratory glossitis, is a painless condition notable for erythematous “islands” of denuded papillae surrounded by elevated whitish borders (Fig. 43-2). The islands appear to migrate over the surface of the tongue over time, akin to the movement of continents on the globe. The etiology is unknown, with allergy, infection, and stress all implicated as potential contributors. It generally resolves without specific treatment over a period of weeks to months.

Figure 43-2 Geographic tongue.

From Fitzpatrick JE, Morelli JG [eds]: Dermatology Secrets, 3rd ed. Philadelphia, Mosby, 2007, Fig. 58-5, p. 467.

13 What is a ranula? How does it differ from a mucocoele?

A ranula is a mucous retention cyst on the floor of the mouth, under the tongue (Fig. 43-3). A mucocele is a retention cyst located most commonly in the mucosa of the lower lip (Fig. 43-4). Both can range from several millimeters to a centimeter in diameter, are painless, and are felt to arise following trauma to the ducts of minor salivary glands. Treatment is surgical excision.

Figure 43-3 Ranula.

Figure 43-4 Mucocele.

From Swartz MH: Textbook of Physical Diagnosis: History and Examination, 4th ed. Philadelphia, Saunders, 2002, Fig. 11-13, p. 295.

14 What are the most common causes of stomatitis in young children?

Viral infections most commonly cause stomatitis in young children (< 6 years old). Herpes simplex virus, usually type I, causes a syndrome of very painful vesicles and gingival inflammation, sometimes to the point of bleeding, in the anterior mouth and tongue. Herpes stomatitis is often associated with high fevers (temperature of 39–40° C), headache, and cervical adenopathy. Coxsackie viruses cause a more benign vesicular inflammation of the posterior pharynx. Also known as herpangina, this infection causes pain, low-grade fever, and drooling. An acral viral exanthem (hand, foot, and mouth disease) is seen with some strains of coxsackie virus. Both infections are most common in the toddler age group, and both are treated symptomatically with topical or systemic analgesics. There is some evidence that acyclovir given early in the course of herpetic stomatitis may alleviate the symptoms.

15 Name three eponymous anaerobic infections associated with the mouth

Fisher MC: Other anaerobic infections. In Behrmann RE, Kliegman RM, Jenson HB (eds): Nelson’s Textbook of Pediatrics, 17th ed. Philadelphia, Saunders, 2004.

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