Many parents sometime will find that their child or baby have a bluish-purple bump on their gingiva (gum).  There is no need to panic, this is a fairly common development and is known as an eruption cyst or eruption hematoma.

Children’s teeth form inside of a protective enclosure. As the teeth form, they move through the bone and then through the gums until they make it into the mouth.  An eruption cyst occurs during the tooth’s final entry into the mouth, just under the surface of the gums. The protective enclosure around the teeth may leak fluid causing accumulation between the tooth and gum tissues. An opposing tooth due to bite force can also cause fluid and possible blood to accumulate. The color of the tissue around the tooth is dependent on the amount of blood that accumulates. The gum tissue can be swollen and appear to be a translucent color, bluish purple, or even dark red and brown. Although the eruption cyst or eruption hematoma are unattractive and often cause parents to worry, most are actually painless.

How are Eruption Cysts Treated?

Most of these hematomas will not require any special treatment. The tooth will break through the hematoma and emerge just like any normal teething experience. The broken tissue will heal on its own and probably won’t even cause any discomfort. Should parents have any concerns regarding the cyst they shouldn’t hesitate to call their pediatric dentist. Parents should describe the appearance, the time they noticed its presence, and any symptoms. The pediatric dentist will instruct as to whether or not the child should be seen in office. Occasionally, the excess fluid from the eruption cyst may stop the tooth from emerging through the gum. Rarely, a minor procedure under local anesthesia might be necessary to expose the tooth and allow complete eruption.

The tongue and lips are attached to the gingiva by a muscular attachment called a frenum. There are two frena (the plural form of frenum) in the mouth.  1. Lingual frenum, which connects the tongue to the floor of the mouth, and the 2. maxillary labial frenum, which connects the inside of your upper lip to your gums just above the upper two front teeth. These frena can sometimes prevent normal function or create pain. Surgical removal of the frenum is called a frenectomy. Today, laser dentistry offer a more comfortable treatment alternative to use of surgical scalpel (blade) with minimal local anesthesia and bleeding, and without the need for sutures (stitches).

Sometimes, the lingual frenum can cause a condition called ankyloglossia or “tongue-tie” which occurs when the attachment runs all the way to the tip of the tongue causing restrictive protrusion of the tongue. Children are able to accommodate well to a restrictive lingual frenum and can eat and speak normally.  If the attachment causes abnormal function such as speech impairment, breastfeeding problem in infants (poor latch) then a lingual frenectomy may be necessary to give the child normal tongue function and feeding.

A prominent maxillary labial frenum can cause a large gap (diastema) to occur between the upper two front teeth. Immediate treatment is not necessary unless the frenum is causing pain on the upper lips and gums or poor oral hygiene. Despite parental concern for the gap, treatment should be delayed until the upper permanent teeth have come in. Many times, the replacement of the baby teeth with permanent teeth will naturally close the gap between the two front teeth.  If the gap doesn’t close, then orthodontic treatment (braces) will be needed. During orthodontic treatment, if after closing the gap, the teeth begin to drift apart again and the frenum is deemed to be the cause, then a maxillary labial frenectomy is recommended. A maxillary labial frenectomy should only be attempted after the gap is closed. The frenectomy may cause scar tissue formation between the teeth which makes it impossible to close the gap.  Thus, maxillary labial frenectomy should only be performed after it has been shown that the frenum is the causative factor in maintaining the gap between the maxillary central incisors.  This determination can occur after the permanent canines erupt (come in).  Therefore, a maxillary labial frenectomy is indicated after the age of 11 or 12.

Children’s teeth begin forming before birth and become visible as early as 4 months old.  The typically permanent teeth begin appearing at age 6 but can be as early as age 5. There are 20 primary teeth and 32 permanent teeth.  Below is the teeth eruption guide. Some children do exhibit earlier or later eruption pattern.  Any extreme deviation in tooth eruption should be discussed with your dentist.

Sealant is a white or clear plastic material that is applied to the biting (depression and grooves) surfaces of the back permanent teeth. The sealant acts as a barrier, protecting the decay-prone areas of the back teeth from plaque and acid. Although thorough brushing and flossing can remove food particles and plaque from smooth surfaces of teeth, they cannot always get into all the nooks and crannies of the back teeth to keep them clean. Sealant protects these vulnerable areas from tooth decay by “sealing out” plaque and food.

Procedure:  It’s a quick and painless process. It is applied on the first and second molars (age 6 and 12 respectively). The tooth is cleaned and dried before placing an acidic gel on the teeth. This gel roughs up the tooth surface so that a strong bond will form between the tooth and the sealant. After a few seconds, the gel is rinsed off and dried again before applying the sealant onto the grooves of the tooth. A special blue light is then shone to harden (cure) the sealant.

Dental Sealant (step by step)

While fluoride is a naturally occurring compound, it can still cause side effects when consumed in large doses.  In 2015, the U.S. Department of Health and Human Services (HHS) released its recommendation lowering the optimal concentration of fluoride to 0.7 mg per liter of water from the previous 1962 of 1.2 mg per liter.

Dental fluorosis happens when you consume too much fluoride while your teeth are still forming in the gingiva (gums). This results in white spots on the surface of the teeth. Other than the appearance of white spots, dental fluorosis doesn’t cause any symptoms or harm. It affects only children under the age of 8 who have unerupted permanent teeth. Children are also more likely to swallow toothpaste, which contains significantly more fluoride than fluoridated water. Children’s risk of developing dental fluorosis can be reduced by supervising them when they brush their teeth to make sure they aren’t swallowing large amounts of toothpaste.

The American Academy of Pediatric Dentistry recommends a tiny smear of fluoridated toothpaste to be used for children under the age of 2. The illustration shows the incorrect amount of toothpaste for a child. This amount could be swallowed by the child increasing or exceeding the daily amount necessary.  A pea-sized amount is recommended for children under six years of age.  You should also keep it out of reach; kids are sometimes tempted to eat toothpaste.

Dental examinations include the following:

• • Digital x-rays to assess proper tooth development and healthy eruption of primary and permanent teeth
  • Thorough examination of the teeth, looking for areas of decay, teeth that will be exfoliating (coming out soon), future orthodontic needs, and any treatment diagnosis
  • Head, neck, and mouth visual examination

The digital dental radiographs are taken at least once per year for children at low risk for dental caries and every 6 months for children at high risk. They are only used as needed for diagnosis. If a visual examination revealed spacing between the teeth allow for complete visual view of all sides of the teeth, then the dentist may opt not to take any radiographs.

Dental radiographs serve as an adjunct to the dentist’s in best diagnosis and treatment. The American Dental Association (ADA) encourages dentists and patients to discuss dental treatment recommendations, including the need for X-rays, to make an informed decision together.  Radiation exposure associated with dentistry represents a minor contribution to the total exposure from all sources, including natural and man-made.

The National Council on Radiation Protection and Measurements (NCRP) has estimated that the mean effective radiation dose from all sources in the U.S. is 6.2 millisieverts (mSv) per year, with about half of this dose (i.e., 3.1 mSv) from natural sources (e.g., soil, radon) and about 3.1 mSv from man-made sources.  About half of the man-made radiation exposure is related to CT scanning.  Dental radiographs account for approximately 2.5 percent of the effective dose received from medical radiographs and fluoroscopies. While radiation exposure is low with digital radiographs, no one should receive more radiation than absolutely necessary. Protective lead aprons and thyroid collars should be used, especially for pregnant women, women of childbearing years and children.

Most injuries to primary teeth occur at 18 – 30 months of age, the toddler stage. As they learn to walk, they may fall forward landing on their hand and knees. The teeth most frequently injured are the upper central incisors, especially with protruding teeth being two to three times more prone. There are various types of injuries:

Luxation:  This is the displacement of teeth with damage to the supporting structures which include periodontal ligament (PDL) and alveolar bone. The PDL supports the tooth to the socket.

1. Concussion: The tooth is not mobile and is not displaced
2. Mobility: The tooth is loosened but is not displaced from its socket
3. Intrusion: The tooth is driven into its socket. This compressed PDL commonly causes a crushing fracture of the alveolar socket.
4. Extrusion: This is the dislocation or displacement of the tooth from the socket. The PDL is torn.
5. Lateral Extrusion: The tooth is displaced in a labial, lingual or lateral direction. The PDL is usually torn and fracture of the supporting alveolar bone.
6. Avulsion: The tooth is completely displaced from the alveolus. The PDL is severed and fracture of the alveolus may occur.

The sequel to traumatized teeth may be devitalization due to lack of blood supply to the teeth. The potential sequel includes:

1. Pulp hyperemia: Sensitive to percussion, transillumination of the crown with bright light. The condition may be reversible.
2. Pulp Hemorrhage: Due to hyperemia there is bleeding from the capillaries, leaving blood pigments deposited in the dentinal tubules. In mild cases, the blood is resorbed and very little discoloration or may be lighter in color in a few weeks. In severe case, the discoloration continues for the life of the tooth.
3. Calcific Metamorphosis: The pulp chamber and canal are gradually obliterated by progressive deposition of dentin. These teeth usually appear yellow and no treatment is recommended.
4. Pulp Necrosis: In the absence of blood circulation, the pulp becomes necrotic (dead). Radiograph may show radiolucency indicating a granuloma or a cyst with often a parulis clinical evident at the level of the tooth’s root apex. The treatment required may be a pulpectomy with a resorbable material (zinc oxide and eugenol) or extraction due to risk to the permanent development teeth.
5. Inflammatory Resorption: This can occur either on the outside root surface or inside the pulp chamber or canal. If treated, the tooth is treated with resorbable zinc oxide paste.
6. Replacement Resorption: Also termed ankylosis, results after irreversible injury to the PDL. Alveolar bone directly contacts and becomes fused with the root surface. If there is delayed or ectopic the eruption of the permanent tooth then extraction should be performed.

Pulpotomy: Indicated for vital primary teeth with exposed pulp (nerve chamber). Best performed when:

1. There is spontaneous pain
2. Swelling around the gingiva
3. Tenderness to percussion
4. Abnormal mobility
5. Presence of fistula (infection)
6. Presence of sulcular drainage (infection)
7. Presence of internal resorption
8. Pulp calcification
9. Pathologic external root resorption
10. Periapical radiolucency on radiograph
11. Radiolucency around the root on radiograph
12. Excessive pulpal bleeding or decaying odor

The procedure involves caries removal if needed and accessing or unroofing the pulp chamber with a sterile bur. A sterile large spoon excavator is used to incise and remove all pulpal tissue with the coronal chamber being careful not to pull out the root tissue. Bleeding is controlled with cotton pellet pressure. A zinc oxide and eugenol base mixture is inserted with a final restoration.

Pulpectomy: This is the complete removal of the pulp of the tooth which implies a root canal therapy but utilizing a physiologically tolerable and resorbable material. The treatment is indicated if the degenerative pulpal changes have involved the toot tissue. Often the dentist may use this approach even under extreme circumstances when the potential for success is low or not ideal, for example in the case when the second primary molar has severe caries but the first permanent molar has not erupted. If there is no ability to place a space maintainer, the option is to try to do the pulpectomy on the second primary molar to extend it existence till the first permanent molar erupt. The natural primary tooth is the best space maintainer although a distal shoe spacer may or may not be an option.

Premature loss of a tooth in the primary dentition may compromise the eruption of succedaneous (replacement) if there is a reduction of space in the arch length.

Band and Loop

Fixed space maintainers can be unilateral or bilateral. Space maintainers also can be placed on the mandibular or maxillary arch.

Distal Shoe Appliance

The thumb and finger habits make up the majority of the oral habits. The effects on the dentition is dependent on the intensity (amount of force), duration (time spent) and frequency (number of times throughout the day) of the habit. Duration plays the most critical role in tooth movement in digit habit. It takes 4-6 hours of force per day to cause tooth movement. Thus, a child who sucks intermittently with high intensity may not produce much tooth movement at all, whereas a child who sucks continuously can cause a significant change. Symptoms of an active habit are 1. anterior open bite 2. Facial movement of the upper incisors and lingual movement of the lower incisors 3. Upper jaw constriction (narrowing).

Timing of treatment is critical. A child should be given the opportunity to stop the habit naturally before eruption of the permanent teeth, thus treatment is performed between age 4 and 6 years. The approaches are:

1. 1. Reminder therapy: This gives the willing child the opportunity to quit but needs a little help. For example, the use of a band aid or ill-tasting solution painted onto the sucking digit.
   2. Reward system: In this the child agrees to stop the habit for a certain length of time and receives a reward if accomplished. The reward should be special enough to give the child incentive to quit. The more involved the child is the better the chance for success. This can involve the use of stickers being placed on a calendar at the end of the day when the habit is not conducted.
      3. Appliance therapy: This is used if the habit persist following reminder and reward therapy and the child truly wants to stop the habit. The appliance physically discourages the habit by making it difficult to suck the digit. The parent and child should be informed that this is not a punishment but rather a permanent reminder.

Bruxism is a grinding of the teeth and is usually reported to be a night activity though some children do so during the day. The masticatory muscle soreness and temporomandibular joint pain may be attributed to bruxism. The cause of bruxism is not known. Most explanations are centered around local, systemic and psychological reasons. The local theory speculates that bruxism is a reaction to an occlusal interference, high restoration or irritating dental condition. The systemic factors include intestinal parasites, subclinical nutritional deficiencies, allergies and endocrine disorders. The psychological theory claims the manifestation of personality disorder or increased stress. Children with musculoskeletal disorder (cerebral palsy) and those with mental retardation commonly grind their teeth. Treatment should begin with occlusal equilibration to remove interferences. If occlusal interference or equilibration is not successful then referral to the necessary physician to determine or treat systemic problems. If neither two steps are not successful then a mouthguard appliance can be constructed of soft plastic to protect the teeth and eliminate the grinding habit. If the habit is due to psychological factors, then refer to child development specialist.

The American Association of Orthodontists considers orthodontic treatment as being very important part of children’s oral health care. Teeth are very important in many ways. Teeth work together to make it possible to bite and chew properly, and contribute to clear speech.  Proper functioning teeth tend to have a pleasing appearance. A beautiful smile is the outward sign of good oral health, and sets the stage for overall well-being.

The American Association of Orthodontists recommends children get their first orthodontic check-up at the first recognition of an orthodontic problem, but no later than age 7. At this age, children have a mixed dentition, primary (baby) and permanent teeth. During each dental visit an assessment of the dental changes is conducted to note any possible problems as the permanent teeth take the place of baby teeth, and as the face and jaws are growing. If a problem exists, or if one is developing, treatment will be recommended or referred to an orthodontist who will then further advise you on whether treatment is recommended, when it should begin, what form the treatment will take, and estimate its length.

Sometimes preventive or interceptive orthodontic treatment (first phase) is all that is needed. More often, patients will require a comprehensive orthodontic treatment (second phase) after most or all of the permanent teeth are present. This will complete the tooth and jaw alignment that was started in the first phase of preventive or interceptive treatment.