3.3 Oral Examination

Enamel Hypoplasia and Enamel Demineralization

To look for enamel hypoplasia or demineralization, retract the lips and cheeks (lift the lip). Children with low birthweight, developmental delays, or certain genetic syndromes may be at increased risk for enamel hypoplasia, which seems to be a predisposing factor for dental caries, especially in the maxillary incisors and primary molars, and for enamel demineralization, which is often characterized by chalky white spot lesions. Hypoplasia usually appears on the middle or occlusal (incisal) third of the teeth, whereas demineralization from poor oral hygiene and an acidic oral environment most often occurs near the gingival line.

Dental Caries

Wipe the teeth with a 2” x 2” gauze square, and retract the lips and cheeks. Look for obvious decay and/or erosion that may result from frequent reflux, altered salivary flow, cariogenic diets, or inappropriate feeding or eating practices. Early childhood caries occurs in primary teeth and is most often located on the facial and lingual surfaces of maxillary incisors and on first molars.

 

Dento-Facial and Developmental Anomalies, Delayed Tooth Eruption, and Malocclusion

During the extraoral examination, note any craniofacial anomalies or facial asymmetry. Most children with cleft palate/cleft lip who were born in the United States are under the care of a multidisciplinary team of health professionals beginning immediately after birth, since treatment consists of a sequence of corrective surgeries and therapies. Children moving from other countries to the United States may not have received early care and surgery. Children with fetal alcohol syndrome will have facial abnormalities with at least two of the following signs: head circumference below the third percentile, small eye openings, flat and long upper lip, underdeveloped midface, or flattened nose bridge. Children affected by the Zika virus may experience microcephaly and other anomalies.

Intraorally, check for malocclusion in the primary teeth that may create problems in the permanent teeth. Malocclusions occur frequently in children with developmental problems.

Delayed tooth eruption is seen in children with certain genetic disorders, particularly Down syndrome, and in children with developmental delays that involve the oral musculature. Check the sequence of eruption to determine whether it is normal or delayed, or if there is any other problem that is interfering with tooth eruption. Children with altered muscular tone also may have malocclusions.

Note any deviations or morphologic defects in teeth that may be due to growth disturbances, muscle dysfunction, Down syndrome, cleft palate/cleft lip, hypothyroidism, ectodermal dysplasia, or other conditions that are associated with variations in the number, size, and shape of teeth.

During the intraoral examination, observe the number of teeth. Supernumerary teeth as well as fused and geminated teeth may be seen. Anodontia and hypodontia also are associated with genetic disorders and syndromes. These conditions can affect the development and eruption of the permanent teeth. Fused teeth may be more susceptible to dental caries at the site of the fusion of the crowns. Damage to the developing teeth can be caused by laryngoscopy and endotracheal intubation in infants born preterm or who experienced other problems after birth. If these conditions are detected in the primary dentition, parents should be advised about the implications and about future treatment-planning needs.

Diseases of the Gingiva and Other Soft Tissues

Examine the gingival tissue, noting any inflammation, bleeding, infection, tissue overgrowth, or tissue destruction from self-injurious behavior. (See section 3.5, Anticipatory Guidance, Oral Trauma and Injury.)

Early severe gingivitis or early periodontitis can occur in children who have impaired immunity or connective tissue disorders, take medications that cause gingival overgrowth, have inadequate oral hygiene, or have drying of the gums and teeth caused by mouthbreathing.

 

While inspecting the soft tissues, also check for signs of other infectious diseases such as herpetic gingivostomatitis, herpes labialis, or fungal infections, especially if the child is on regular antibiotic therapy, or if you suspect child abuse or dental neglect. (See section 3.4, Child Abuse and Dental Neglect.)

 

 

Oral Reflexes and Oral Sensitivity
Assess for oral hypersensitivity, excessive gagging, swallowing difficulties, or oral hypotonicity. Any of these factors can interfere with optimal feeding, toothbrushing, and the provision of oral health care. Food adherence and retention in the mouth due to food consistency (e.g., a soft diet), inadequate oral hygiene, or abnormal muscle control are risk factors for oral disease.

Oral Trauma and Injury
Children who experience some types of seizure disorders, atypical protective reflexes, muscle incoordination, behavioral disorders, or attention deficit disorders are at high risk for facial and intraoral trauma. Children may engage in self-injurious behaviors such as face or mouth banging; picking or scratching the skin or gum tissue; biting the tongue, cheek, or lip; placing sharp or hot objects in the mouth; or eating non-nutritive substances (pica). Look in the mouth for any fractured, intruded, extruded, missing, or mobile teeth; lacerated frenums; scar tissue; and signs of abrasion or erosion of the enamel. Lip and facial lacerations are common and can easily become infected. (See section 3.5, Anticipatory Guidance, Oral Trauma and Injury.)

Dental trauma may be an important marker for child abuse because craniofacial, head, face, and neck injuries occur in more than half of the cases of child abuse. (See section 3.4, Child Abuse and Dental Neglect.)