Chapter [I]

Review of Literature

Oral health of children is important to their overall well-being. The mouth cannot be separated from the rest of the body, oral health cannot be considered separate from the rest of children's health. Oral health actually includes all the sensory, digestive, respiratory structural and emotional functions of the teeth. Oral health must be considered in the context of social, cultural, and environmental factors. Dental disorder have a profound impact on children, and the burden of untreated dental health problems is substantial. Untreated dental cavities can result in pain, infection, tooth loss, difficulty eating or speaking, and poor appearance, all of which present challenges for maintaining self-esteem and attentiveness to learning (Maas, 2010).

Anatomy and physiology of oral cavity

The oral phase includes all swallowing activities that occur within the oral cavity. It can be divided into preparatory and transfer phases. The oral cavity is bounded by the lips anteriorly; the cheeks laterally; the teeth, alveolar ridge, hard palate, and soft palate anteriorly; the teeth, alveolar ridge, floor of mouth, and tongue inferiorly; and the soft palate, uvula, tonsillar pillars, and posterior part of the tongue that form the posterior opening of the oral cavity or the oropharyngeal isthmus (Massey, 2006). In the mouth, a combination of hard and soft tissue areas form the occlusion (bite). The teeth, along with upper and lower jaw bones, are among the hard tissues. The soft tissue includes the gums, tongue, and salivary glands (Swain, 2009).

Teething

A tooth or teeth come through the gum line (tooth eruption). This is a normal process of the body. The first set of teeth a child has is called the primary or deciduous teeth. As a child loses the primary teeth, the second set of teeth, known as the permanent or secondary teeth, comes through the gum line. Teeth are named for their location in the mouth and the function they serve. Incisors cut the food, and canines tear the food. Premolars crush the food, and permanent molars grind the food (Mclaughlin and Pizzi, 2009).

The child may have some discomfort. The baby’s gums may become sore and irritated, and may become cranky or fussy. To help reduce the irritation suggests rubbing baby’s gums with a clean finger. Gently massaging the area will help the discomfort of baby’s mouth. Letting child chew on something cold (like a chewing ring) will help a lot. The teething process will not make child ill. It often seems that child has a cold or mild fever along with the drooling and chewing (Sciarra, 2005).When Teething gels, biting on something hard (such as a teething ring), paracetamol or ibuprofen seem to help some babies. Not use lemon juice on baby's gums. Lemon juice has a lot of acid and can harm new teeth by dissolving the tooth enamel (Wake and Hesket., 2009).

Fig (1): Eruption tooth cutting through

Wale, J. (2010): Human teeth.p4.Wikimedia Foundation.org.22/5/2010. Available on:

Eruption of primary teeth

The tooth breaking through the gum line. In babies, tooth eruption is also called teething. The timing of tooth eruption differs from one child to the next. While the timing may vary, the order of tooth eruption is generally the same. Generally, the average child has their full set of 20 primary teeth by the age of three years(ADA, 2008).

Fig (2): Child have erupted tooth

Table (1): Primary teeth eruption

The following table shows when the primary teeth (baby teeth) erupt. It is important to note that the eruption time varies from one child to another (Wale, 2010).

Primary teeth
Upper Teeth / Eruption Time / Lower Teeth / Eruption Time
Central Incisor / 8 to 12 months / Central Incisor / 6 to 10 months
Lateral Incisor / 9 to 13 months / Lateral Incisor / 10 to 16 months
Cuspid / 16 to 22 months / Cuspid / 17 to 23 months
First Molar / 13 to 19 months / First Molar / 14 to 18 months
Second Molar / 25 to 33 months / Second Molar / 23 to 31 months

Wale, J. (2010): Human teeth.p4.Wikimedia Foundation.org.22/5/2010. Available on:

Fig (3): Primary teeth chart

Jain, R.K. (2010): Anatomy and development of the mouth and teeth. Lucile Packard children hospital. California. p2.Available on

Permanent teeth

The permanent teeth start to develop in the jaws after a child is born. By about 21 years, the average person has 32 permanent teeth: 16 in the upper jaw and 16 in the lower jaw. Permanent teeth are also known as adult teeth or secondary teeth(ADA, 2008).

Table (2): Permanent teeth eruption

The following table shows when the permanent teeth (adult teeth) erupt(Wale, 2010).

Permanent teeth
Upper Teeth / Eruption Time / Lower Teeth / Eruption Time
Central Incisor / 7 to 8 years old / Central Incisor / 6 to 7 years old
Lateral Incisor / 8 to 9 years old / Lateral Incisor / 7 to 8 years old
Cuspid (Canine) / 11 to 12 years old / Cuspid (Canine) / 9 to 10 years old
First Bicuspid (Premolar) / 10 to 11 years old / First Bicuspid (Premolar) / 10 to 12 years old
Second Bicuspid (Premolar) / 10 to 12 years old / Second Bicuspid (Premolar) / 11 to 12 years old
First Molar / 6 to 7 years old / First Molar / 6 to 7 years old
Second Molar / 12 to 13 years old / Second Molar / 11 to 13 years old
Third Molar (Wisdom Tooth) / 17 to 21 years old / Third Molar (Wisdom Tooth) / 17 to 21 years old

Wale, J. (2010): Human teeth.p4.Wikimedia Foundation.org.22/5/2010. Available on:

Fig (4): Permanent teeth chart


Jain, R.K. (2010): Anatomy and development of the mouth and teeth. Lucile Packard children hospital. California. p2.Available on

Teeth Types

The teeth in an adult are divided into four categories-incisors, canines, premolars and molars. Incisors are single-rooted teeth with a sharp, thin edge. These teeth are located at the front of the mouth and are designed to cut food. The tongue side of an incisor is shaped like a shovel to help guide food into the mouth. Canines, also known as cuspids, are located at the "corner" of a child dental arch. The canines cut and tear foods. The canines are the longest teeth in the human mouth and thus also are some of the most stable teeth. Premolars, also called bicuspids, are a cross between canines and molars and sit behind the canines. These teeth have pointed cusps on their cheek side that hold the food, while the cusps on the tongue side grind it. Molars are called (wisdom teeth), are the last teeth, farthest back in the mouth on all sides. In between are the second molars, also called 12-year molars. Molars are large teeth with broad surfaces designed for crushing, grinding and chewing food. On the upper jaw, the molars have three well-separated roots; on the lower jaw, the molars have two roots(Bird and Robinson., 2009).

Fig (5):Human teeth

Wale, J. (2010): Human teeth.p4.Wikimedia Foundation.org.22/5/2010. Available on:

Fig (6):Structure of teeth (Parts of tooth)

Urquhart, D. (2010): The development and structure of tooth and teeth. Tooth and teeth.com.p1.A

  • Cementum - a layer of tough, yellowish, bone-like tissue that covers the root of a tooth. It helps hold the tooth in the socket(Nagel, 2009). Cementum is almost as hard as enamel, but also continues to grow throughout life from cells in the pulp. This allows for continual reattachment of the periodontal ligament to the bottom of the tooth, and provides for a measure of healing for victims of periodontal disease if caught early enough. It's only found on the underside of the tooth, below the gum layer, and is thickest at the bottom point of the tooth(Urquhart, 2010).
  • Crown - the visible part of a tooth(Nagel, 2009).
  • Dentin - the intermediate tooth layer, the dentin is harder than bone. The Dentin is a spongy, porous form of specialized bone created to provide shock absorbing cushions for dental enamel, which is quite brittle(Nagel, 2009).It surrounds the entirety of the pulp and is capped by dental enamel above and cementum below the gum line. Dentin also continues to grow throughout life. It's also much more susceptible to quick decay and damage because of its delicate internal structure(Urquhart, 2010).
  • Enamel - the hard shiny, white outer surface of the tooth, it is hydroxyapatite, which is a crystalline calcium phosphate(Nagel, 2009). Dental enamel covers the entire top of the tooth, and is very hard, very brittle, and slightly translucent. If the underlying dentin has started to decay or change color, the change is frequently visible through the enamel. Because dental enamel has a very dense mineral structure, it's highly susceptible to acidic damage, which is how most cavities start. In addition, dental enamel can be worn away by other acids such as lemon juice and excessive abrasion from dental hygiene efforts (Urquhart, 2010).
  • Nerves & Pulp - nerves transmit signals (conveying messages like hot, cold, or pain) to and from the brain, the soft center of the tooth. The pulp contains blood vessels and nerves; it nourishes the dentin(Nagel, 2009).
  • Periodontal membrane/ligament - the fleshy tissue between tooth and the tooth socket; it holds the tooth in place (Nagel, 2009). The periodontium is the supporting structure of a tooth, helping to attach the tooth to surrounding tissues and to allow sensations of touch and pressure. It consists of the cementum, periodontal ligaments, alveolar bone, and gingiva. Alveolar bone surrounds the roots of teeth to provide support and creates what is commonly called an alveolus, or "socket". Lying over the bone is the gingiva or gum, which is readily visible in the mouth (Iverson, 2010).
  • Root - the anchor of a tooth that extends into the jawbone. The number of roots ranges from one to four (Nagel, 2009).

Nutrition and dental health

Adequate nutrition provides the basis for development of all tissues and structures of the body including those in the oral cavity (Palmer, 2007).Good nutrition is essential for good physical health. Nutrition also plays a key role in the development and maintenance of a healthy mouth, especially the teeth and gums. Good dental health begins early in life and must be practiced throughout life. Tooth development begins shortly after conception, usually between the sixth and eighth weeks of gestation and continues throughout pregnancy. It seems to take severe nutritional deficiencies in the mother to cause obvious changes in tooth formation in the child. However, slight deficiencies may cause changes in tooth structure that will leave a tooth at greater risk for decay later in life(Anderson and Brown., 2008).

Effects of specific nutrients on developing dentition

  • Fluoride is one of the essential elements for a good dental health. It helps teeth fight against plague and can neutralize harmful effects of acids in saliva. Receive great amounts of fluoride from water and tea consume regularly. Also, this element can be found in walnuts, fish and other foods(Matz, 2010).
  • Protein helps teeth form. Kids who don't get enough protein and are malnourished have a higher risk for cavities. Choose lean sources of protein like fish, chicken and beans. These foods are also high in iron, magnesium and zinc, which help to build teeth and bones (Matz, 2010).
  • Iron deficiency can cause gum problems and bring to gums inflammation. Liver, red meat, beans, apples and other products are prefect sources of iron (Palmer, 2007).
  • Calcium this element protects teeth against tooth enamel damages and the effects of temperature changes. Lack of calcium in body, teethcan start crumbing. Therefore, it is vital for good dental health to eat the foods with high content of calcium, such as dairy products, broccoli, soy, sesame, figs (Matz, 2010).
  • Phosphorus. This element is important for the strength and durability of tooth enamel. Also, phosphorus plays a role for proper digestion of calcium. Phosphorus can be found in fish, eggs, milk, beef and other foods(Palmer, 2007).
  • Vitamin A helps tooth and enamel form. Orange fruits and vegetables like carrots and sweet potatoes are rich in vitamin A(Palmer, 2007).
  • Vitamin B helps keep gum tissue healthy. Whole-grain breads and cereals and green, leafy vegetables contain vitamin B (Palmer, 2007).
  • Vitamin K keeps gums healthy and controls bleeding. Dark leafy greens are good sources of vitamin K(Palmer, 2007). Vitamin D it is vital for effective digestion of both phosphorus and calcium. Body can synthesize Vitamin D itself when skin received good amounts of sunlight. Natural sources of Vitamin D include eggs, fish, and mushrooms (Palmer,2007).
  • Vitamin B6 is also important element of effective nutrition for dental health. Vitamin B6 deficiency can cause mouth dryness, as well as little wounds and cracks in our mouth. Receive good amounts of this vitamin regularly from eat potato, spinach, tomatoes, strawberries, carrot, cauliflower and other foods (Palmer, 2007).
  • Vitamin C consuming a good amount of Vitamin C can guarantee a good condition of gums. Sources of Vitamin C, including oranges, lemons, onions, carrots, and sugar-beet (Palmer, 2007).

Table (3): Effects of nutritional problems on tooth development

Period / Effects of Nutritional problems
Pre-eruptive period: Crown formation and mineralization within the jaw / Developing enamel and dentin are susceptible to nutritional imbalances as any other developing tissues
Maturation period: Teeth are erupting into oral cavity and roots forming / Deficiencies affect secretory or maturation stages of enamel formation
Secretory stage deficiencieshypo plastic lesion
Maturation stage deficiencies hypo mineralized defects
Maintenance period: Teeth are functioning in the oral cavity / Lack of constant mineralization from saliva, food, beverages and oral care products results in decreased resistance to dental caries

Palmer, C. A. (2007):Diet and nutrition in oral health.2nd ed.Pearson prentice Hall.New Jersey.U.S.A. p278

Fluoride and dental health

Fluoride is a naturally occurring trace element present in small but widely varying amounts in soil, water, plants, and animals. Fluoride may be used systemically or topically. Systemic fluoride is ingested, absorbed, and incorporated into developing bone and teeth. Usually, delivery of system fluoride is accomplished through community water fluoridation or through fluoride supplementation. Topical fluorides are applied to erupted teeth and are not incorporated within the developing tooth structure. It serves to strengthen the surface of the developed teeth. Fluoridation of community water supplies is the most cost effective and practical public health measure for prevention of tooth decay. The practice of giving children fluoride supplements has been developed for use in areas where optimally fluoridated water supplies are not available. It is important to note that fluoride recommendations for prescription of supplements varies by age of child(Whitford, 2008).

Table (4): Fluoride Supplementation: Concentration of fluoride in drinking water in parts per million (PPM) Table:

Age / <0.3 PPM / 0.3-0.6 PPM / >0.6 PPM
Birth - 6 months / 0 / 0 / 0
6 months-3 years / 0.25 / 0 / 0
3 years-6 years / 0.50 / 0.25 / 0
6 yrs-at least 16yrs / 1.0 / 0.50 / 0

Whitford, G. (2008):Georgia oral health prevention program the school nurses role in oral health.DHR.p14

Oral hygiene and dental health

Oral hygiene includes all the processes for keeping the mouth clean and healthy. Good oral hygiene is necessary for the prevention of dental caries, periodontal diseases, bad breath and other dental problems. Good oral hygiene habits will keep away most of the dental problems saving from toothaches and costly dental treatments. The interesting part is that it can be achieved by dedicating only some minutes every day to dental hygiene care. The main purpose of dental hygiene is to prevent the build-up of plaque, the sticky film of bacteria that forms on the teeth. Bacterial plaque accumulated on teeth because of poor oral hygiene is the causative factor of the major dental problems. Poor oral hygiene allows the accumulation of acid producing bacteria on the surface of the teeth. The final effect of poor oral hygiene is the loss of one or more teeth (Mayo Foundation for Medical Education and Research, 2010).

Tooth brush

Toothbrush with a small head is recommended, so that children can use it easily, and it will not cause gagging when they brush their back teeth. The handle should have the correct length and thickness. It must be easy to use and provide a firm grip. Brushes for children often have handles and heads that are brightly colored, and show cartoon characters. Brushing needs to be a fun experience (Goldstein and Peters., 2009).

Fig (7): Type of tooth brush


Toothbrushes for children /
Modified toothbrushes

Goldstein, T.and Peters, R.(2009):Tooth decay causes and prevention. Simply teeth.com. p5. Available on.

Fig (8):Method of teeth brushing (proper brushing techniques).