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Eruption of the Primary Dentition in Human Infants: a Prospective Descriptive Study

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Eruption of the Primary Dentition in Human Infants: a Prospective Descriptive Study Scientific Article Eruption of the primary dentition in human infants: a prospective descriptive study Sarah A. Hulland, BSc (Hons), DDS, MSc, DPD, FRCD(C) James O. Lucas, MDSc, LDS, FRACDS, FICD Melissa A. Wake, MBChB, MD, FRACP Kylie D. Hesketh, BBSc(Hons) Dr. Sarah A. Hulland is the clinical research associate, Department of Dentistry; Dr. James O. Lucas is the deputy director, Department of Dentistry; Dr. Melissa A. Wake is the director and Ms. Kylie D. Hesketh is the research assistant, Research and Policy Unit, Centre for Community Child Health and they are all at Royal Children’s Hospital, Melbourne, Australia. Correspond with Dr. James Lucas at [email protected] Abstract Purpose: This study investigated the clinical process of the emer- eral theories have been suggested including the alveolar bone gence phase of eruption of the primary dentition including length growth theory; the root growth and pulpal proliferation theory; of time taken to erupt and the association between soft tissue changes and the blood and tissue fluid pressure theory.7-10 The most and stages of eruption. likely source of eruptive forces has been identified as those as- Methods: Twenty-one children aged 6 - 24 months at com- sociated with the periodontal ligament.7-9 Research in this area mencement of the study were recruited from three suburban daycare has revealed that no single causative factor adequately explains centers in Melbourne, Australia. Daily oral examinations of each the mechanism of tooth eruption although it is clear that a child were conducted for seven months. complete, essentially time-specific, biological interaction occurs Results: One hundred twenty-eight teeth were observed dur- between multiple tissue coordinates to create the eruptive ing eruption. Swelling very infrequently accompanied tooth event.7-9 eruption and in all cases was mild. Forty-nine percent of observed For human teeth to erupt, they must proceed through three teeth demonstrated gingival redness during the emergence stages phases. The first is pre-emergent development which involves of eruption, but there was no significant relationship between red- the early part of tooth formation, when the dental follicle en- ness and specific stages of eruption. Mean duration of eruption, larges until partial root development has been completed. The from palpable enlargement of the gingival tissue to full eruption, overall dental movement is minimal, but it may have a slight was 2.0 months (range 0.9-4.6 months). The average rate of erup- facial transposition in the alveolar bone.11 The second phase tion was 0.7 mm per month. Many of the deciduous teeth appeared involves the movement of the tooth intra-osseously through the to demonstrate an “oscillating” pattern of eruption, (emerging and processes of resorption of the overlying tissues creating an erup- then retreating before emerging again). Timing of oscillation was tive path, and generating an eruptive force to move the tooth not specific to stage of eruption or tooth type. This was defined as vertically.12 The third phase is post-emergent development a “transitional” phase of eruption which appears to be common. which involves the movement from the time the tooth emerges Conclusion: The results suggest that eruption of the primary through the gingiva until it reaches occlusal contact with its dentition is often accompanied by redness, but not swelling, of the antimere.13 The source of the eruptive force has not yet been gingival tissues. For some children, there also appears to be a “tran- established, but it has been suggested that the metabolic activ- sitional” eruption phase for primary teeth. (Pediatr Dent ity within the periodontal ligament may play a role, particularly 22;415-421, 2000) for the post-emergent stage of eruption.14 Human growth hormone (HGH) is known to affect growth and tooth erup- eething is viewed by parents and health care profession- tion and it has been suggested that the periodontal ligament is als as a significant event in the growth and development influenced by a diurnal-nocturnal rhythm in HGH secretion.15- Tof the child. It has been suggested that this experience 18 often causes distress and discomfort to both infants and their From the time the crown of the tooth emerges, it may erupt parents.1-4 To dentists and physicians, the eruption of teeth at a rate of 1 to 2 mm/mo until the full eruption is reached has long been a source of intrigue and controversy with incom- and then it will continue eruptive movement at a slow rate plete understanding of the mechanisms of tooth eruption, the throughout its lifespan, as determined by studies of the per- process initiation and determination and the chronology of manent dentition.8 In the permanent dentition, the tooth clinical events.5-7 typically erupts about 4mm in 14 weeks (1.1 mm/mo), but the Teething is the biological expression of tooth movement, equivalent values for the primary dentition have not yet been in a predominantly axial direction, from the tooth’s develop- established.13 The complete eruptive size for the primary den- mental position within the jaws to its emergence in the oral tition, measured from the incisal or cuspal height to the cavity.8 How this process occurs is yet to be clarified but sev- Received December 21, 1999 Revision Accepted June 2, 2000 Pediatric Dentistry – 22:5, 2000 American Academy of Pediatric Dentistry 415 Methods This prospective cohort study was conducted in three subur- ban day care centers situated in close proximity to the Royal Children’s Hospital, Melbourne, Australia. Eligible subjects were healthy infants aged between 6 and 24 months at commencement of the study who attended one of the participating long day care centers three or more days per week. No child was known to have a medical condition that might have influenced tooth eruption. Written parental consent was obtained prior to commencement. Parents and day care staff were informed that they would be participating in a study of health and minor illness (including the effects of common conditions such as teething) in children attending long day care centers. In the week prior to commencement of the study, a pilot study was conducted in one of the participating centers to es- Fig 1. E0; no clinical signs of eruption. tablish standardized working procedures. During this time a cemento-enamel junction, has been determined to be 5.6mm,19 trained dental hygienist underwent specific training with a se- but the rate of eruption has not been reported in the literature. nior pediatric dentist focusing on examination techniques, It has been suggested that the eruption of primary teeth may recognition of stages of tooth eruption and standardized record be accompanied by certain local disturbances such as ‘balloon- keeping. ing of the gums’ over unerupted teeth, flushing of one or both During mid-morning on each weekday for seven months cheeks (sometimes with a bright spot referred to as the ‘hectic beginning May 1997, the dental hygienist conducted an oral spot’ in the center of the flushed area), inflammation of the examination of each participating child when present at gingiva, oral ulcers and increased drooling.1 Soft tissue re- daycare, with the aid of a back reflecting dental mirror. The sponses to the eruptive process have been reported since the examination involved tactile and visual observations of the al- second century A.D.2 Redness of the mucosa has been con- veolar ridges at each of the primary dentition sites to identify sidered a sign of impending tooth eruption with the prevalence any redness or swelling and stage of tooth eruption. All obser- of this phenomenon reported to be in the range of 30–90% of vations were recorded on a separate sheet each day and placed children.1,2 immediately into a locked study box to minimize recorder bias Although the literature clearly presents information on the (aura effect). Teeth were numbered using standard dental estimated ages of eruptive and exfoliative history for the life notation. Once each tooth was recorded as reaching the full span of each primary tooth,20,21 there is little information avail- eruption state (one quarter of the crown of the tooth erupted) able to describe the ‘typical’ clinical eruptive history for each consistently, it was pre-entered on the record forms as being tooth. The majority of information available regarding the rate in that state constantly. of eruption has been derived from studies on the permanent Redness was recorded as the presence (R1) or absence (R0) dentition with the results extrapolated to describe the primary of redness on the alveolar ridge. Four stages of swelling were dentition. The aim of the present study was to describe the defined: (S0) normal alveolar ridge (absence of swelling); (S1) emergence phase of eruption of the primary teeth, including slight soft tissue swelling—slight enlargement of the soft tis- the length of time individual primary teeth take to emerge sue on or lingual to the alveolar ridge; (S2) obvious soft tissue through the soft tissues, and the association of soft tissue swelling—fluctuant swelling over the tooth without sign of changes with the stages of tooth eruption. cystic formation; (S3) eruption cyst—fluid filled enlargement which might be blue in color if filled with blood. Five stages of eruption were defined: (E0) no signs of eruption (Fig 1); Fig 2a. E1; palpable- enlargement of tissues suggesting imminent Fig 2b. E1; palpable- enlargement of tissues suggesting imminent eruption (incisor). eruption (molar). 416 American Academy of Pediatric Dentistry Pediatric Dentistry – 22:5, 2000 Fig 3a. E2; emergent- gingival parting but incomplete incisal edge Fig 3b. E2; emergent- gingival parting but incomplete cusp emergence emergence (incisor).
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