Michael J. Sigal, DDS, MRCDC Norman Levine, DDS, FRCDC Infant Oral Health Care SUMMARY RESUME The family physician/pediatrician who sees Le medecin de famille ou le pMdiatre qui, dans un a child from birth as part of the well-baby programme de surveillance du b6b6 en bonne sante, suit un enfant depuis la naissance est dans une situation privilegi6e visit program is in the best position to pour identifier pr6coc6ment les problemes dentaires et identify early dental problems and to 6duquer la famille sur l'importance des soins dentaires educate the family about early oral pr6ventifs. Les dentistes ne voient pas regulierement les preventive health care. Since children enfants de moins de trois ans; ceux-ci sont donc expos6s a under three years of age are not seen d6velopper des problemes dentaires. Cet article couvre routinely by dentists, they are at risk of brievement les domaines de la pathologie orale infantile, la pr6vention precoce, la pouss6e des dents, les habitudes de developing dental disease. This paper sucer son pouce et les traumatismes dentaires chez les briefly covers the areas of infant oral enfants qui commencent a marcher. Le m6decin sera donc pathology, early preventive care, teething, en meilleure position pour recommander aux parents le suckling habits, and dental trauma in the meilleur moment de consulter un dentiste. toddler. The physician will then be in a better position to recommend to parents when they should seek dental advice and treatment for their young children. (Can Fam Physician 1988; 34:1419-1424.) Key words: infant dental care, pediatrics

Dr. Sigal is an Assistant from dental disease. In such instances, should be informed that by the end of Professor in the Department of the first visit will have been too late to the first trimester, all of the fetus' pri- Paediatric Dentistry, Faculty of prevent the onset of disease. More- mary teeth begin to form, and that at Dentistry of the University of over, various dental concerns, such as birth all 20 primary-tooth crowns are Toronto. Norman Levine is oral lesions, oral trauma, or habits that almost completely formed. To ensure Professor and Head of may require treatment and/or consulta- the development of sound enamel and Department of Paediatric tion, may arise during the first two dentin, all that is required is a well- Dentistry, Faculty of Dentistry of years of the child's life. For these rea- balanced diet. Prenatal calcium or fluo- the University of Toronto. sons, professional dental health care ride supplements do not provide any Requests for reprints to: Dr. M. should begin during the infant period real benefit to the developing teeth, J. Sigal, Department of Paediatric and not at the age of three years.' since the period of crown mineraliza- Dentistry, Faculty of Dentistry, The family physician who sees the tion is mostly postnatal.2 Unless it is University of Toronto, 124 child from birth for well-baby visits is absolutely necessary, tetracycline Edward Street, Toronto, Ont. in the best position to identify early should not be prescribed to the mother M5G 1G6 dental problems, to recommend because it will cross the placental bar- HE TRADITIONAL VIEW is prompt treatment, and to educate the rier and produce characteristic staining that dental care should begin family about early oral preventive of the primary teeth; the permanent somewhere between the age of two- health care. This care will give the successors, however, will not be af- and-a-half to three-and-a-half years, young child the best possible chance to fected. 3 The prospective mother when children reach a developmental grow up free of dental disease. should be encouraged to receive pre- stage at which they will co-operate in The initial phase in a complete pre- ventive dental care during the course of the initial dental examination and treat- ventive dental program is a prenatal her pregnancy.3 ment. However, if sound preventive dental discussion incorporated into the In certain women, because of their practices are not already inplace by this prenatal classes that most expectant altered hormonal state, the gingival tis- age, the child may already be suffering parents attend. The expectant mother sue will over-react to local irritants CAN. FAM. PHYSICIAN Vol. 34: JUNE 1988 1419 such as plaque to produce a condition means she had originally planned, Prior to extraction, the physician known as pregnancy gingivitis. This whether bottle or breast. The feeding should make sure that the baby has re- condition is characterized by process will be messy, but the baby will ceived a Vitamin K injection at birth; if erythematous, edematous, gingival tis- be able to take sufficient food to thrive. this injection has not been given, ex- sues that bleed easily after brushing or Once their initial shock has been over- traction should be postponed for three probing. In addition, the local reaction come, the parents should be informed weeks until the child's own hemostatic may be more severe, resulting in the of the CL/P treatment centres to which mechanism is functioning. On re- formation of a pregnancy tumour that their baby will be referred for ongoing moval, bleeding should be minimal, appears clinically like a pyogenic care. and the baby should resume a normal granuloma.4 A sound preventive pro- Initial oral examination may disclose feeding/sleeping pattern almost imme- gram carried out both at home and in that the baby has a soft-tissue swelling diately. Ifthe tooth is not mobile, itmay the dentist's office can control the onset located on the anterior maxilla or on be left in situ, provided that the incisal and progression of pregnancy gingivi- other areas of the alveolar ridges. edges feel smooth to the touch. tis. If a pregnancy tumour develops, it These lesions are usually a congenital Intra-oral infections are rare in the is usually excised after the child is epulis or granular cell myoblastoma; newborn child, though neonatal can- born, and recurrence is rare if oral hy- benign lesions thought to be hamar- didiasis producing thrush does occur giene is good. Finally, the prospective tomas rather than other benign neo- occasionally.4 This disorder will pre- mother should be advised to obtain all plasms may also be present.5 If a le- sent as a white plaque-like lesion, that preventive and restorative dental care, sion does not interfere with the airway when rubbed with a piece of gauze except X-rays, for the treatment ofcar- or the feeding process, it may be left in sponge, will leave a raw bleeding sur- ies during her pregnancy, but to post- situ, and monitored; in this case, sur- face. Definitive diagnosis is made by pone any elective treatment until after gery will be performed at a later date, obtaining a cytology smear, which will the birth of her baby. when the child is better able to tolerate a demonstrate an active candida infec- At the time of birth and while the general anesthetic and the surgical pro- tion. The cause of this infection is the baby is still in the nursery, the attending cedure. If, however, the lesion inter- baby's exposure to the candida organ- physician should perform a quick oral- feres with feeding or airway, it should ism in the mother's vaginal canal dur- facial examination. Certain dento-fa- be excised. Once excised, these lesions ing the birthing process. The lesions re- cial anomalies may be present that re- will not recur. spond well to treatment with nystatin, quire treatment or referral for Small, discrete, cyst-like lesions which can be taken orally to achieve a treatment. A baby may be born with may be noted along the alveolar ridges systemic effect or applied directly to what appears to be a micrognathic man- or along the mid-palatal region. These the lesions with gauze. dible, resulting in a retrognathic ap- lesions are called "Bohn's modules" In babies from birth to six months of pearance. Such a mandible may be part and "Epstein's pearls" respectively age, the normal gum pads are firm to of the Pierre Robin syndrome which and are a result of epithelial remnants touch and covered by keratinized also includes glossoptosis and a cleft from the embryonic period undergoing mucosa. The ridges may have a seg- lip/palate.4 The immediate concern is cystic degeneration in their respective mented appearance that reflects the po- one ofairway obstruction caused by the areas. These lesions are asymptomatic sition of the developing primary teeth, tongue assuming a posterior position. and will resolve spontaneously within but there is no real occlusion at this The infant is managed by keeping it in a the first few months of life.6 time. Oral health care should begin at prone position at all times, especially Finally, initial oral examination may this time, before the eruption ofthe pri- for feeding, and may require tube feed- disclose natal teeth, usually in the man- mary teeth. After each feeding, the ing. If the tongue continues to obstruct dibular incisor region (Figure 1). 7 ridges should be wiped clean with a the airway, it may be necessary to su- These teeth are the mandibular primary piece of gauze to remove any remain- ture it in place to the lower lip. The incisors and not an extra set of teeth. ing food material and to familiarize the long-term prognosis for such children They have emerged in the oral cavity baby with someone doing something in is quite good. There is usually a period because they developed in a superior his or her mouth to promote oral hy- of accelerated mandibular growth so position within the body of the mandi- giene. Tooth decay is still one of the that within several months the airway ble. They are usually quite mobile. The most common bacterial diseases of will no longer be at risk, and by age of presence of such teeth, or even one childhood, and it can easily begin be- six years the facial appearance should tooth, may make initial attempts at fore the baby reaches the age of one- no longer be retrognathic. nursing difficult: during the suckling and-a-half years. If a preventive dental Cleft lip, with or withoutcleft palate, motion, the dorsal surface ofthe tongue program is begun early in life, the onset or isolated cleft palate, is another fre- will pass over the sharp incisal edges of ofdecay can be prevented, and a "cav- quent anomaly that may present at the tooth/teeth and may become lacer- ity-free" condition maintained.8 birth; the reported incidence of this ated and secondarily infected. Finally, The most important aspect of caries anomaly is 1:800 to 1:1000 births.4 these teeth usually emerge without any prevention that must be established by The initial concerns relate to appear- root development, and so there is poor the time the child is six months old is the ance and feeding. The appearance can attachment. There is a possibility, provision for systemic fluoride supple- be improved simply by placing adhe- therefore, that they may be dislodged; ments. The optimum level of fluoride sive tape over the cleft lip and pre-max- ifthis happens, there is a risk ofaspira- in the systemic water supply is 1 ppm, illa; the tape will decrease the size of tion. The usual course oftreatment is to or 1 mg fluor/day for a child of three the defect. The mother should be en- extract the teeth with a piece of gauze years. The breast-fed infant will re- couraged to feed her baby by whatever without using any local anesthetic. ceive a trace amount of fluoride 1 420 CAN. FAM. PHYSICIAN Vol. 34: JUNE 1988 (<0.05 ppm) in its mother's milk; visional diagnosis offoreign-body aspi- ism, hypopituitarism, and a local ob- cow's milk contains <0.1 ppm offluo- ration. Examination failed to establish struction such as dilantin-induced gin- ride. In a region where there is no fluo- the presence of any obstruction, but it gival hyperplasia or an odontoma or ride in the water supply, supplements at was discovered that all children had supernumerary tooth.4 By the age of a level of 0.25 mg fluoride ion per day been given several applications of two-and-a-half to three years, how- should be given from six months ofage. teething gels that contained ben- ever, most children have complete pri- Multi-vitamin preparations that contain zocaine. The benzocaine, once in- mary dentition. fluoride are currently available and can gested, can produce methemoglo- At this stage, parents must be made be used if the physician considers that binemia which results in cyanosis. aware of the importance of the child's the correct level of fluoride is dis- These babies were all treated with 02 primary teeth. These teeth are used for pensed.2' 9 and intravenous methylene-blue 1% mastication, which helps to develop the The first primary teeth emerge into 0.1-0.2 mg/kg; they recovered un- craniofacial complex, as well as aiding the oral cavity when a baby is about six eventfully. 11 In addition, the use of a proper nutrition. A healthy dentition months old; their emergence is usually teething gel prior to a feeding may improves a child's appearance and pro- preceded by the symptoms of teething. serve to anesthetize the epiglottal re- motes social acceptance which, in turn, At this age the baby is no longer pro- gion, which could predispose a baby to promotes psycho-social development. tected by the circulating maternal anti- aspirate part ofa meal, with associated The teeth have a part in the develop- bodies, and thus may be prone to the de- untoward sequelae. If parents wish to ment of speech. The primary teeth also velopment of teething. Moreover, as use a teething gel, the physician should determine and maintain the space that the teeth emerge into the oral cavity, stress the dangers and insist that ifthey will be required for the eruption of the oral bacteria may enter the systemic are to be used at all, it must be in mod- permanent teeth and the permanent oc- circulation via the gingival crevice and clusion that will If these teeth so give rise to an inflammatory reaction eration. develop. that results in teething. During the period of tooth eruption, are not properly cared for, the child The signs and symptoms of teething a blue-coloured, elevated, cyst-like le- may suffer the development of caries may be any of the following: painful sion may be noted over the alveolar and its sequelae. gingiva, increased chewing, increased ridge in the region of a tooth that will Again, the importance ofprevention drooling, restlessness, irritability, dis- evidently erupt soon (Figure 2). This must be stressed to the parents of the ruption of eating/sleeping patterns, lesion is called an "eruption young child aged from one-and-a-half low-grade fever, and loose stools. hematoma" or "bruise". It is caused to two-and-a-half years. Using a fluori- However, high fever and serious illness by the breakdown of small non- dated toothpaste in an amount no larger are not a result of teething. resorbed blood vessels that are posi- than a pea, the parent should brush the Treatment is primarily supportive tioned on top of the erupting tooth, re- child's teeth well at least once a day. and symptomatic. The baby may be al- sulting in the accumulation of blood Since most children will swallow the lowed to chew on a chilled teething ring within the tissue spaces. This lesion is toothpaste, it is important to keep their or a cool damp washcloth, be given an not painful, and no treatment is re- systemic exposure to a minimum, to acetamenaphen product, and encour- quired, as it will break down spontane- prevent acute toxicity, evidenced by aged to drink. 10 The physician should ously as the tooth erupts through it. 4 nausea and vomiting, or chronic toxic- not recommend the use ofteething gels. Delayed eruption of primary teeth ity which would produce enamel In some instances, infants have been sometimes characterize several condi- fluorosis. The parents should also be admitted to emergency wards ofhospi- tions such as Down syndrome, given nutrition counselling in the mat- tals appearing cyanotic and with a pro- cleidocranial dysostosis, hypothyroid- ter of those foods which are dentally

Figure 1 Figure 2 Natal Tooth Eruption Hematoma

This eruption hematoma is located between the maxillary This natal tooth is evident on the crest of the mandibular central incisor and cuspid, where it appears as a raised blue alveolar ridge of a one-day-old infant. lesion. CAN. FAM. PHYSICIAN Vol. 34: JUNE 1988 1421 preferable to other foods, such as morphology, colour, or number. Three pattern of enamel defect is caused by a sweets, which will predispose the child of the more common conditions illus- localized/temporary disruption of the to develop caries. 9 trating this are: ameloblast function that is related to an For the young baby (ofsix months to * ectodermal dysplasia. There may be intra-uterine metabolic disturbance one-and-a-half years) the most impor- complete or partial absence ofprimary possibly caused by a maternal fever or tant aspect ofnutrition counselling is to teeth. Any teeth that are present are toxemia. Secondly, if the mother was inform the parents of the dangers of usually quite conical in shape; typi- given tetracycline during the second or putting a child to bed with a bottle of cally, they have been termed "witches' third trimester of her pregnancy, the any liquid containing a natural or re- teeth". Children with this anomaly are dentine ofthe child's primary teeth will fined sugar, or of demand breast-feed- usually characterized by complete or be stained brown to black to a degree ing all through the night. Either ofthese relative alopecia, lack of sweat glands, that reflects the period of mineraliza- practices will produce nursing car- exhibiting as an intolerance to heat, and tion during which tetracycline was pre- ies. 12,13 The characteristic pattern of absence of or malformed finger/toe sent. The permanent teeth, however, the caries attack is that the primary nails. The condition is inherited as a will not be stained as a result of the maxillary incisors are severely in- sex-linked recessive trait. 14 child's intra-uterine exposure to the volved, while the mandibular incisors * amelogenesis imperfecta. All the drug. are caries-free (Figure 3). The reason teeth may have an irregular, rough, pit- Children under three years of age is that during the suckling process, the ted surface consistent with amelogene- may present to the physician's office tongue will lie over the mandibular in- sis imperfecta, an autosomnal domi- with a variety of soft-tissue lesions. cisors and thus protect them. Then, nant/recessive disorder resulting in One ofthe most common lesions is pri- while the baby is sleeping, the last improperly formed enamel.4 mary herpetic gingivostomatitis, which amount of formula, juice, or breast * dentinogenesis imperfecta. All the is caused by the herpes type I virus. It is milk will be held against the maxillary teeth may have a gray, opulent appear- rare to have a baby present with this incisors by the upper lip. The local bac- to the age of six months sufficient substrate ance caused by the early loss ofenamel. disease prior teria will then have The appearance is consistent with the because of the protection provided by to metabolize and thus produce the acid antibodies. On ex- in a localized caries at- autosomnal dominant disorder of den- circulating maternal which results tinogenesis imperfecta, which may be amination, the child is found to be irri- tack. Once caries has developed, the and usually teeth can be restored, usually under associated with osteogenesis imper- table, febrile, in oral pain, general anesthesia, or extracted. If a fecta.4 showing evidence of cervical lym- mother insists that her child requires a In general, if all a child's teeth ap- phadenopathy. Intra-orally, there will bottle inbed at night, recommend that it pear abnormal in some way, the cause be large, irregularly shaped, ulcerated contain only plain water. is likely to be a genetic problem, and he regions on all the mucosal surfaces, With the combination ofproper diet, or she should be referred for dental as- which may be covered with a necrotic early oral hygiene, and systemic and sessment and management. slough layer. The initial stage is vesicu- topical fluorides, we can promote a Two other common enamel defects lar, but this is rarely seen. The gingiva generation ofcaries-free children, pro- may present in the young child. One is are acutely inflamed and erythemic. vided that the dental-care program be linear enamel hypoplasia/hypocal- The lesions heal spontaneously and initiated at or before the eruption ofthe cification, a condition in which only a without scar formation in 10-14 days. first primary teeth. localized area of several teeth appears Treatment is primarily supportive and Once present in the oral cavity, the affected, while the remainder of the symptomatic. Acyclovir is used only if dentition may exhibit anomalies in crown appears normal (Figure 4). This more severe systemic involvement ap-

Figure 3 Figure 4 Early Caries Early Linear Hypoplasia _ .....W.,.s -IImmxmmTI,

..., '. ,::,n:": :- .... ::. ::::,,., A two-and-a-half-year-old child with localized linear the middle of the pri- A two-year-old child with nursing-bottle caries, involving the hypoplasia primarily involving region maxillary four incisors. mary cuspids (eye teeth). 1988 1422 CAN. FAM. PHYSICIAN Vol. 34: JUNE pears to be developing. In the following Gingival hyperplasia may be identi- the physician should examine the tod- years, the child is susceptible to recur- fied on routine medical examination. dler's teeth and soft oral tissues for any rent herpetic infections that may take This condition, which is characterized signs of trauma. As children learn to the form of recurrent herpes labialis, by edematous, boggy-appearing gin- crawl or walk, it is quite common for characterized by a large irregularly- giva that bleeds easily, could be the in- them to fall, and many of them hit their shaped ulcer on the lips, or ofrecurrent itial presentation of leukemia in a teeth. Ifa tooth appears to be chipped or intra-oral herpes, characterized by le- young child. 16 Gingival hyperplasia, discoloured, the physician should ex- sions on the keratenized tightly-bound which appears pink and is of firm con- amine the soft tissues in the area for any mucoperiosteum of the hard palate or sistency, is usually drug-induced by di- evidence of an abscess, gum boil, or attached gingiva. In all cases, the le- lantin or cyclosporin. In either drug-in- draining fistula (Figure 6). If any of sions will resolve spontaneously.4 duced case, initial treatment consists of these disorders is present, the child The other common ulcerative lesion improving the level of oral hygiene, should be referred for a dental evalu- is the apthous ulcer. It is still not clear which will reduce the rate ofhyperplas- ation. If a child totally avulses a pri- whether this ulcer is caused by an auto- tic growth, and then of excising the ex- mary tooth after a fall or blow to the immune type of response or by a reac- cess tissue as required to maintain den- mouth, the tooth should never be re-im- tion to a form oforal streptococci. Ap- tal function and esthetics. 17 planted into the socket, as is done with thous ulcers are usually singular or The final two dental concerns of permanent teeth, because such treat- occur in small groups that do not coa- which a medical practitioner should be ment may damage the developing per- lesce to form a larger lesion-like her- aware in the child of one to three years manent tooth. 19 pes. Intra-orally, they occur primarily are sucking habits and dental trauma. in the non-keratinized loose alveolar All non-nutritive sucking habits, be Overview mucosa (buccal mucosa, lip, soft pal- it ofthe thumb or a pacifier, will have a This paper has presented a case for ate, tongue, floor of mouth). Unlike similar effect on the development ofthe 18 establishing a preventive dental assess- herpes, the lesions lack a vesicular occlusion ifdone to excess. Sucking ment and treatment program that can be stage. Once formed, the ulcers are is a normal part of the growth and dev- incorporated into the well-baby visits quite painful. Again, they heal sponta- lopment ofa baby and should notbe dis- provided by family physicians. By ex- neously and without scar formation in couraged or even commented on. Ifit is amining the infant for oral problems seven to 14 days. As with herpes, treat- done to excess, however, it will eventu- and by providing early preventive ment is primarily supportive and sym- ally result in an anterior open-type bite counselling, it is possible for the physi- pomatic. In extensive episodes, topical of malocclusion (Figure 5). The par- cian to prevent many forms of dental steroid ointment may be applied; alter- ents should be told that as children disease and thus promote the total natively, rinsing with tetracycline has grow older (3-5 years) and are exposed health of child patients. U been shown to resolve the lesions. 15 to more peer pressures, they usually Finally, examination of the tongue drop the habit spontaneously. When the may disclose what appears to be an ul- habit is discontinued, the malocclusion Acknowledgements cerated lesion that is asymptomatic. will self-correct, and there will be no We wish to thank Ms. Alice Kato for This lesion may change its shape and need for immediate orthodontic treat- her secretarial assistance in the prepa- position with time, or it may resolve ment. In general, parents need not feel ration ofthis manuscript and Mr. Steve spontaneously. It is called "geographic guilty that their child has a sucking Burany and Mrs. Rita Bauer, Photog- tongue" or "benign migratory glos- habit. raphers, Audio-Visual Department, sitis". Its etiology is unknown, and no Finally, during the course of the for their time and expertise in prepar- treatment is required. well-baby visits or annual assessments, ing the photographs.

Figure 5 Figure 6 Anterior Open-Bite Malocclusion Fractured Lateral Incisor

Anterior open-bite malocclusion resulting from a sucking An eight-month-old toddler with a fractured lateral incisor habit. that has caused a buccal abscess (gum boil). CAN. FAM. PHYSICIAN Vol. 34: JUNE 1988 1423 References 1. Croll TP. A child's first dental visit: a Canadian Library protocol. Quint Int 1984; 6:625-37. 2. Nikiforuk G. Understanding dental car- of Family Medicine ies. In: Prevention: basic and clinical as- The Library Service of The College of Family Physicians of Canada pects. II. Basel: Karger, 1985; 37-8, 133-4. Services of the Library 3. Chiodo GT, Rosenstein DI. Dental treatment during pregnancy: a preventive For Practising Physicians approach. J Am Dent Assoc 1985; 110:365-8. * Literature on 4. Shafer WG, Hine MK, Levy BM. Text- -advances in diagnosis and therapy book of oral pathology. 4th ed. Philadel- pharmaceutical information phia: W.B. Saunders, 1983; 361, 682, 11, practice management topics 268, 393, 261. * Medical literature searches 5. Henefer EP, Abaza NA, Anderson SP. Congenital granular-cell epulis. Oral Surg * Copies of medical artides Oral Med Oral Path 1979; 47:515-8. * Information on ordering books and joumals 6. Jorgenson RJ, Shapiro SD, Salinas CF, et al. Intraoral findings and anomalies in For Researchers in Family Medicine neonates. Pediatrics 1982; 69:577-82. m Literature searches and bibliographies 7. Kinirons MJ. Prenatal ulceration of the tongue seen in association with a natal m Location of documents and studies tooth. J Oral Med 1985; 40:108-9. m Literature on research methodology 8. Goepferd SJ. Infant oral health: a ration- ale. JDent Child 1986; 53:257-60. For Teachers of Family Medicine 9. Goepferd SJ. Infant oral health: a proto- m Preparation of booklists on family mediiane topics col. J Dent Child 1986; 53:261-6. * 10. Pierce AM, Lindskog S, Ham- Advice on collecting literature to support programs marstrom L. IgE in postsecretory * Searches of medical literature on topics related to ameloblasts suggesting a hypersensitivity reaction at tooth eruption. J Dent Child training family doctors 1986; 53:23-6. Residents in Family Medicine 11. McGuigan MA. Benzocaine-induced methemoglobinemia. Can Med Assoc J * Literature searches 1981; 125:816. in support of research projects 12. Derkson GD, Ponti P. Nursing bottle * Advice on using syndrome: prevalence and etiology in a non-fluoridated city. J Can Dent Assoc libraries and bibliographic resources 1982; 48:389-93. Allied Health Personnel 13. Curzon MEJ, Drummond BK. Case report: rampant caries in an infant related to * Literature on areas of overlap of the various prolonged on demand breast feeding. J with medicine Paed Dent 1987; 3:25-8. professions family 14. Waggoner WF. Multidisciplinary Charges for Bibliographic Services treatment of a young child with hypohidrotic ectodermal dysplasia. Spec Care Dent 1987; 7:215-7. Literature searches for CFPC Members: One free search per year, $6/search thereafter. No charge to 15. Antoon JW, Miller RL. Apthous ul- cers: a review of the literature on etiology, family medicine residents. pathogenesis, diagnosis and treatment. J Articles copied ...... 15 ¢/page Am Dent Assoc 1980; 101:803-8. Books/AVloans ...... No Charge 16. Curtis AB. Childhood leukemias: in- General Reference ...... No Charge itial manifestations. JAm DentAssoc 1971; 83:159-63. Literature searches for non-members: 17. Butler RT, KalkwarfKL, Kaldahl WB. $15/search. Searches limited to family medicine topics. Drug-induced gingival hyperplasia: Articles copied ...... 15 ¢/page phenytoin, cyclosporin, and nifedipine. J Am Dent Assoc 1987; 114:56-60. To use the services of CLFM, contact the librarian at: 18. Bishara SE, Nowak AJ, Kohout FJ, et Canadian Library of Family Medicne al. Influence of feeding and non-nutritive Natural Sciences Centre sucking methods on the development of the dental arches: longitudinal study of the first University of Western Ontario 18 months of life. Ped Dent 1987; 9:13-21. London, Ont. N6A 5B7 19. Levine N. Injury to the primary denti- Telephone (519) 661-3170 tion. Dent Clin North Am 1982; 26:461-80.

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