What is the Differential Diagnosis of Abnormally Colored Teeth?

A 15-month-old male came to clinic for his health supervision examination. His parents are concerned that his teeth are developing a gray-black hue for the past couple of months.
He has been well otherwise.
The past medical history reveals he was diagnosed with iron deficiency anemia and treated with supplemental iron drops for the past 2 months.
The review of systems is negative.
The pertinent physical exam shows a healthy toddler with normal growth parameters. His teeth have a gray to black color uniformly across the teeth, but slightly more prominent at the gingival line. No caries are noted.
The diagnosis of therapeutic iron ingestion was made. The parents were told that this is extrinic staining of the teeth that will improve after he stops taking the iron and proper oral hygiene is all that is needed. He had been previously referred for his first dental visit and the need for dental health supervision was reiterated.

Dental abnormalities are common in healthy children. These can include anomalies of tooth eruption, morphology, number, size, shape, tooth structure and caries. Dental caries are one of the most common chronic health problems in children.

The American Academy of Pediatric Dentistry and the American Academy of Pediatrics recommends an oral examination for all infants within 6 months of the eruption of the first tooth and no later than 12 months of age.

Learning Point
Intrinsic staining is foreign substance incorporation into the developing enamel or changes in the hardness or thickness of the dental hard tissues. Treatment requires professional bleaching or esthetic restoration such as veneers.
Extrinsic staining is superficial and caused by plaque or other discoloring substances sticking to the teeth. Treatment includes removal by proper oral hygiene and abrasive agents used in dental cleanings. Extrinsic staining is not a risk to dental decay.

The differential diagnosis of abnormal tooth color includes:

Intrinsic Staining

  • Blue-black
    • Neonatal hyperbilirubinemia
  • Gray
    • Hemorrhage
    • Necrosis
    • Tetracycline
  • Green
    • Biliary atresia
  • Pink
    • Blood resorption
  • Red-pink-brown (due to blood pigments)
    • Anemias
    • Congenital porphyria
    • Cholestatic disorders
    • Hemolysis
  • White (especially spotted)
    • Hypocalcified-hypoplastic disease states
  • Yellow-Brown
    • Calcification
    • Fluorosis
    • Tetracycline

Extrinic Staining

  • Gray-Black
    • Iron
  • Green
    • Chromogenic bacteria
  • Yellow-Brown
    • Foods and beverages
    • Smoking

Questions for Further Discussion
1. What is the normal age range for first primary tooth eruption?
2. What is the normal age range for secondary tooth eruption?
3. What should be done if a child has too few or too many teeth?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for these topics: Dental Care.

To view current news articles on this topic check Google News.

Avery ME, First LR. eds. Pediatric Medicine. 2nd Edit. Williams and Wilkins, Baltimore, MD. 1994:1382-1383.

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:1287.

Yang CW. Pediatric Dental Basics. Cased Based Pediatrics for Medical Students and Residents.
Available from the Internet at http://www.hawaii.edu/medicine/pediatrics/pedtext/s01c12.html (rev.3/2003, cited 5/5/05).

Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

June 29, 2005

What Safety Precautions Should Be Used for Children Around Lawnmowers?

Patient Presentation
A 4-year-old male came to the emergency room after being backed over by a riding lawnmower. Earlier he had been playing at the next door neighbor’s home. He returned to his home for lunch. The 12 year old neighbor was mowing the lawn using a riding lawn mower and was unaware that the boy had returned to the property.
The pertinent physical exam showed his right foot and leg in an extremity air compression cast. He had scrapes and bruising to his abdomen and elbows.
The diagnosis of multiple fractures of the foot and a compound femur fracture were made.
The patient’s clinical course included being taken semi-emergently to the operating room where a partial amputation of his foot was completed along with a rod stabilization of his femur fracture.
In the pediatric intensive care unit, he is currently receiving minimal blood pressure support by a dopamine drip, sedation medication, a morphine drip for pain control, antibiotics and he has had 2 transfusions of packed red blood cells.

Figure 16 – AP (left) and lateral (right) radiographs of the right femur shows a metaphyseal fracture of the right femur with an associated soft tissue defect.

Figure 17 – AP (left) and lateral (right) radiographs of the right foot shows an amputation of the right midfoot with multiple associated fractures and soft tissue defects.

Lawn mower injuries are unfortunately common and have a high potential for moribidity and mortality when they happen.
From 1990-1999, approximately 68,000 injuries were due to lawn mowers. About 9,400 were in children < 18 years of age.
These injuries occur in all age groups: < 5 years = 24%, 5-12 years – 36%, 13-17 years = 40% of injuries. Males account for 75% of the injuries.
All types of injuries occurred and all body parts are injured; 7% of the injuries are amputations and avulsions. Hands and fingers have the highest rate of injuries at 31%, legs = 19% of injuries and feet/toes = 18% of injuries.
Seven percent of pediatric injuries require hospitalization.

Walk-behind mowers including push (or hand) mowers and walk-behind power mowers frequently injure children. The mean age of injuries for walk-behind power mowers is 9 years and 74% are male.
Ride-on power mowers (which includes riding mowers, lawn tractors and garden tractors) are very dangerous for children as they are larger, more powerful and more mechanically complex to operate than walk-behind mowers.
Of ride-on power mower injuries, 20% were in children &lt; 15 years and 12% of these required hositalization. The overall rate of injury for ride-on power mower operators who are 5-14 years is more than twice that of operators who are 15-64 years.
Unfortunately 8% of deaths for ride-on power mowers are for passengers or bystanders whose average age is 4-6 years.

Industry impovements in lawn mower safety designs have lead to decreased injury rates for some types of mowers.

The National Children’s Center for Rural and Agricultural Health and Safety publishes a set of guidelines for children’s participation in farm activities.
These NAGCAT guidelines (The North American Guidelines for Children’s Agricultural Tasks) are for a variety of farm tasks from simple activities such as lifting objects to weeding a garden to very complex activities such as using hydraulic equipment and haying.
The guidelines have been shown to be effective in injury prevention if used by families. The guidelines include use of farm tractors including lawn mower tractors.

Learning Point

There are currently no age-specific criteria established by industry or government for use of lawn mowers.

The American Academy of Pediatrics recommends that:

  • All young children should not be allowed to play in, or be in adjacent areas to where lawn mowers are being used. Children &lt; 6 years old should be kept indoors during this activity.
  • Children should not be allowed to ride as passengers or be towed behind mowes in carts or trailers. They should not be permitted to play on or around mowers when in use or in storage.
  • Most children and adolescents will not be able to operate:
    • A hand mower until at least 12 years of age
    • A walk-behind power mower until at least 12 years of age
    • A ride-on power mower until at least 16 years of age
  • Children and adolescent need to demonstrate the necessary levels of maturity, judgement, strength and coordination to successful operate these machines.
  • Children and adolescents should be educated in proper use and safety of these machines and should be supervised by adults before they use the machines by themselves.

The NAGCAT guidelines says that children as young as 12-13 years MAY use a power lawn mower that is less than 20 horsepower with no implements attached. They do emphasize that the child must again demonstrate maturity, judgement, strength, and coordination for the task, and that parents must provide appropriate education and supervision.
To see specific NAGCAT recommendations, see To Learn More below.

Other appropriate safety precautions include:

  • Long hair should be tied up
  • Use proper eye protection
  • Use proper hearing protection
  • Wear non-skid closed toed shoes
  • Operate the lawn mower
    • Only during daylight hours
    • Not in bad weather
    • In a location with no hazards such as slopes, ditches, fences, gravel, downed tree limbs, etc.

Questions for Further Discussion
1. At what ages should children and adolescents drive all-terrain vehicles?
2. At what ages should children and adolescents drive motorcycles?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

American Academy of Pediatrics. Technical Report: Lawn Mower-Related Injuries to Children. Pediatrics 2001:107;e106. Available from the Internet at: http://www.pediatrics.org/cgi/content/full/107/6/e106 (rev. 06/01/2001, cited 5/4/2005).

Gadomski AM, Ackerman S. Burdick P. Jenkins P. Preventing Farm Injury: A Randomized Field Trial of the North American Guidelines for Childhood Agricultural Injury Prevention. Pediatric Academic Societies Annual Meeting. San Francisco, CA. May 1-4, 2004.

National Children’s Center for Rural and Agricultural Health and Safety. Tractor Fundamental, Tractor Operation. Available from the Internet at: http://www.nagcat.org/poster/TracFund/tracoperation.htm (cited 5/4/05).

National Children’s Center for Rural and Agricultural Health and Safety. Tractor Fundamental, Driving a Farm Tractor. Available from the Internet at: http://www.nagcat.org/poster/TracFund/driving_a_farm_tractor.htm (cited 5/4/05).

Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

June 20, 2005

What are the Criteria for Diagnosing Systemic Lupus Erythematosus (SLE)?

Patient Presentation
A 10-year-old female came to clinic for a second opinion. The patient was well until approximately 6 months ago when she developed ankle pain.
She was treated with anti-inflammatory medications and the symptoms resolved, but during this time she had an erythrocyte sedimentation rate of 62 mm/hr.
Over the past 2-3 months she has had increasing joint pain, intermittent fever and worsening rash. During this time, she was noted to have pyruria and was treated with antibiotics, and at another point she was thought to have mononucleosis but testing was negative.
Over the past few months, she has been stiff in her legs and hands in the morning and for several hours afterwards. She has swelling of her ankles and hands. There is no Raynaud’s phenomenon.
The past medical history shows a hemoglobin of 11.3 one year ago. She has had a rash on her face and hands felt to be due to eczema that was treated by steroids and emollients for 1 year.
The family history is negative.
The review of systems is positive for thinning hair, extreme fatigue, occasional episodes of substernal chest pain, and a 3 kilogram weight loss. Her review of systems is negative for tinnitis, vertigo, focal neurological symptoms, pulmonary symptoms or changes in bowel or bladder habits.
The pertinent physical exam shows a temperature of 38.0 Celsius, blood pressure of 109/57 mg/Hg, weight of 26.5 kg (10th percentile), and a height of 133.7 cm (10th percentile).
She has mild facial edema, prominent malar rash that is deep red in color with multiple coalescent plaques. There are flat, purple macules on both ears and on the dorsum of all fingers. She has a few splinter hemorrhages in her fingernails.
She has some scaly plaques on her lower extremeties. There are multiple erosions in her mouth and buccal mucosa. There is no lymphadenopathy.
On musculoskeletal examination, she has swelling, tenderess, and pain on motion of most small joints of her hands. Both elbows, knees and ankles are warm with swelling and have some limited motion. She has some pain on motion of shoulders and hips.
She walks with her hips and knees flexed and is quite stiff and uncomfortable. The rest of her examination was normal.
The laboratory evaluation included a complete blood count which showed a hemoglobin of 6.8 mg/dl, hematocrit of 20%, white blood cell count of 3.5 x 1000/mm2 and a smear that showed microcytic, hypochromic red blood cells with 1+ teardrops, target cells, and schistocytes. Her C-reactive protein was normal at &lt;0.5 mg/dl.
Her urinalysis showed a specific gravity of 1.025, pH of 6.5 with 3+ protein, 1-10 granular casts, 10-20 hyaline cases, 10-25 white blood cells/ high power field, and 4-10 red blood cells/high power field.
Her electrolytes were normal including calcium, magnesium and phosphorous. Her blood urea nitrogen was 11.6 mg/dl and creatinine was 0.6 mg/dl. Her Alanine Aminotransferase and Aspartate Aminotransferase were slightly elevated, but she had a normal bilirubin. Coagulation studies were normal.
A C3, C4, total hemolytic complement, and an anti-nuclear antibody were pending.
The radiologic evaluation showed a normal chest radiograph.
Because of the increasing systematic symptoms of weight loss, fever, anemia, leukopenia, worsening rash and an abnormal urinalysis with casts and proteinuria, she was clinically diagnosed with systemic lupus erythematosus. She was referrred for urgent evaluation to a pediatric rheumatologist and nephrologist
who confirmed the diagnosis. Her antinuclear antibody came back high at > 1:2560 in a speckled pattern. She was started on hydroxychloroquine and steroids.
The patient’s clinical course over the next few years has included diffuse proliferative lupus glomerulonephritis, difficult to control hypertension and chronic anemia necessitating blood transfusions.

Systemic Lupus Erythematosus (SLE) is a chronic rheumatic disease caused by a copious overproduction of autoantibodies leading to immune complex formation, and binding or deposition of the complexes into tissues. There is wide-spread immune disregulation. This causes damage to any organ in the body but especially the kidney, blood, skin and the central nervous system.
It was first described in the 13th century and its incidence varies by location and ethnicity. It occurs in females more often. The disease may occur at birth but is generally less common in children &lt; 8 years old. Twenty percent of patients present by the second decade of life.

Because SLE can affect any organ, SLE can be in the differential diagnosis of almost any clinical presentation. The most common manifestations are arthritis, dermatitis and nephritis. Specifically patients often complain of prolonged fever, malaise, fatigue, joint pain, and rash.

Initial laboratory studies often include:

  • Complete blood count with platelets, reticulocyte count
  • Electrolytes
  • Liver function tests
  • Kidney function tests
  • Erythocyte sedimentation rate and/or C-reactive protein
  • Anti-nuclear antibody (ANA), anti-double-stranded DNA, anti-Smith antibody and antiphospholipid antibodies (and possibly other autoantibodies also)
  • C3, C4 and total hemolytic complement – these are often low and are markers of disease activity
  • Quantitative immunoglobulins – patients with lupus have high rates of immunodeficiency
  • Chest radiograph and echocardiography – for cardiopulmonary disease
  • Pulmonary function tests – to determine baseline
  • Other tests and imaging for specific presentations such as petechiae, coagulopathy, cerebritis, etc.
  • Biopsies of the kidney, liver or skin may be necessary to determine diagnosis and/or treatment

Treatment includes close follow-up of the patient for progression of disease, and side effects to treatment. This often needs the expertise of many specialists including rheumatology, nephrology, ophthalmology, critical care, social work, physical therapy, and many others.
Common medications used include anti-malarial drugs, steroids, and immunosuppressive agents to treat the primary disease. Antihypertensive agents, calcium and Vitamin D supplements and non-steroidal anti-inflammatory drugs are needed for primary disease and for ameliorating medication side effects.

Learning Point
According to the American College of Rheumatology, there are 11 criteria used for making the diagnosis of SLE in adults. They can be used as a guideline in children. Any 4 criteria are sufficient. ANA is almost always present.
The criteria include:

  • Mucocutaneous
    • Malar rash
    • Discoid rash
    • Nasal or oral ulcer
    • Photosensitivity rash
  • Systemic
    • Arthritis
    • Hemolytic anemia, thrombocytopenia, leukopenia, or lymphopenia
    • Pleuritis or pericarditis
    • Proteinuria (> 500 mg/dl) or evidence of nephritis on urinalysis
    • Seizure or psychosis


    • Postive ANA
    • Positve anti-double-stranded DNA, anti-Smith, or antiphospholipid antibody

The child in this case met 6 criteria: malar rash, oral ulcer, arthritis, hemolytic anemia leukopenia, proteinuria and positive ANA.

Questions for Further Discussion
1. What are some of the common neuropsychiatric presentations of SLE?
2. What are some of the common cardiopulmonary presentations of SLE?
3. What are common medication side effects?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:847-851.

Klein-Gitelman, MS. Systemic Lupus Erythematosus. eMedicine. Available from the Internet at http://www.emedicine.com/ped/topic2199.htm (rev. 7/20/2004, cited 5/2/2005).

Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

June 13, 2005

What Are Some of the Presentations for Child Abuse and Neglect?

Patient Presentation
An 8-month-old female came to the emergency room after a prolonged convulsion. Although previously healthy, she was found during the hospitalization to be malnourished (6.7 kilograms), short (70 centimeters) and had a large head (43 centimeters). The fontanel was not bulging but fresh retinal hemorrhages were seen. A spinal tap showed xanthrochromia. A subdural tap showed blood-tinged fluid. Neuroimaging was not available and subdural fluid was taken off at weekly intervals until she was discharged at 1 month.
Four days later the patient returned to the hospital because of a right leg that was swollen and tender, bruises under the left eye, and petechiae on the abdomen. Again fresh retinal hemorrhages were found. A subdural tap again revealed blood. Radiographs of the extremities showed 5 fractures of the right femur, tibia, and fibula. The mother denied the injuries occurred between the two hospitalizations. The patient remained in the hospital for 5 days and then was discharged to home. The patient was lost to follow-up.

In the United States today this patient would have received different care, but historically this patient’s care was considered standard in 1946 in New York City and elsewhere in the United States. Today this patient would obviously be diagnosed with child abuse because of the multiple presentations including failure to thrive, subdural hemorrhages, retinal hemorrhages, and multiple acute fractures without a history for such injuries.
Although others had studied child abuse, in the United States Dr. John Caffey, a pediatrician and one of the first pediatric radiologists, began studying radiographic cases in the early 1920’s of subdural hemorrhages associated with fractures. These cases over time lead him to believe that this was due to child abuse. Encouraged by others locally who believed in his work, he published his classic article that the current case is modified from entitled, “Multiple Fractures in the Long Bones of Infants Suffering From Chronic Subdural Hematoma.”This article’s publication made others continue to look at the possibility of inflicted injury. In 1953, Silverman published 3 cases where the perpetrator denied abuse, but admitted abuse when confronted with evidence. This article changed the practice of the medical community but did not affect the social climate. Over the next 10 years, more cases were added to the literature. In 1962, Kempe et. al. published the classic article “The Battered-Child Syndrome” in the Journal of the American Medical Association. Although this article is only a case study containing 2 cases, it galvanized not only the medical community but also the political and social communities as well.
It was a turning point in acknowledging child abuse as a distinct health problem, and in beginning the process of prevention, diagnosis and treatment of child abuse and neglect in the United States.

Child Abuse can take many different forms but generally is divided into physical abuse, sexual abuse, and neglect. These often occur concurrently.

Factors associated with an increased risk of child abuse or neglect include:

  • Child – unwanted, disabled, multiple gestation
  • Parent – abused as child, psychiatric illness, mental retardation, substance abuse, teenage mother, unrealistic expectations for child
  • Family – single parent household, isolated family, family violence, many children under age 5
  • Social – poverty, unemployment, violence

The differential diagnosis of child abuse includes but is not limited to:

  • Physical abuse
    • Bruises
      • Bleeding disorders – disseminated intravascular coagulation, Henoch-Schonlein purpura, hemophilia, hemorrhagic disease of the newborn, idiopathic throbocytopenic purpura, fasciitis, meningococcemia, vasculitis
      • Cultural practices – cupping, coin rubbing or rolling
      • Dyes, paints or inks
      • Periorbital swelling – cellulitis or allergic
    • Fractures
      • Normal variant
      • Caffey’s disease
      • Copper deficiency
      • Birth trauma
      • Osteogenesis imperfecta
      • Osteomyelitis
      • Osteoporosis
      • Rickets
      • Scurvey
      • Syphillis, congenital
      • Vitamin A intoxication
    • Burns
      • Cultural practices – cupping, coin rubbing or rolling
      • Diaper rash
      • Drug rash
      • Impetigo
      • Phytophotodermatitis
      • Staphylococcal scalded skin syndrome
  • Sexual abuse
    • Accidental trauma – zip injury, forced retaction of the forskin, straddle injury
    • Anal fissure
    • Bruising
    • Complications of ritual circumcision
    • Crohn’s disease
    • Excessive handing of the penis
    • Paraphymosis
    • Precocious puberty
    • Rectal polyp
    • Sexually transmitted infection
    • Skin changes – candidiasis, bullous impetigo, lichen sclerosis, psoriasis, seborrheic dermatitis, vascular lesion
    • Vaginal foreign body
    • Vaginal tumor

Learning Point
Common presentations of child abuse and neglect include:

  • Physical abuse
    • Abdominal trauma
    • Bites
    • Bruises
    • Burns
    • Fractures
    • Head trauma
    • Play or speech which is violent or abusive
    • Trauma by implement
  • Sexual abuse
    • No physical signs
    • Bleeding of the urethral meatus, vagina or anus
    • Bruising or petechiae of genitals, perineal, gluteal or proximal areas
    • Play or speech which is sexually explicit
    • Irritation or swelling, non-specific
    • Evidence of sexually transmitted infection such as warts, vesicles, etc.
    • Pregnancy
    • Anus changes – anal fissures, perianal thickening or loss of skin folds, gaping or lax anus, scarring
    • Hymen changes – acute tears of hymen, enlarged hymenal opening or attenuation of the hymen, notches in the posterior hymen, scarring
    • Penile changes – torn penile frenulum
    • Urethral changes – damage or dilation to urethral meatus due to foreign body insertion
    • Vaginal changes – vaginal bleeding, labial fusion, foreign body
  • Neglect
    • No physical or sexual abuse signs
    • Abnormal growth pattern or non-organic failure to thrive
    • Chronic infections such as diaper dermatitis
    • Cold injuries
    • Delayed puberty
    • Dirty clothes and/or body
    • Dental caries
    • Infestation such as lice
    • Developmental delay or immaturity
    • Behavior that is listless, distractable, attention-seeking
    • Poor concentration
    • Lack of self-esteem or confidence
    • Truancy, problems with the law
    • Alcohol or substance abuse
    • Self-harm

Questions for Further Discussion
1. As a mandatory reporter of child abuse and neglect, what are your responsibilities?
2. What are the indications for common diagnostic testing such as laboratory testing or radiologic imaging?
3. How can the treating health care provider work with law enforcement officials to appropriately gather and maintain the security of forensic evidence?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Information prescriptions for patients can be found at Pediatric Common Questions, Quick Answers for this topic: Child Abuse.

Caffey J. Multiple Fractures in the Long Bones of Infants Suffering from Chronic Subdural Hematoma. Am J. Roentgenol. 1946:36:163-173.

Silverman FN. Roentgen Manifestation of Unrecognized Skeletal Trauma in Infants. Am J. Roentgenol. 1953;69:413.

Kempe CH, Silverman FN. Steele BF, Droegemueller W, Silver HK. The Battered-Child Syndrome. JAMA. 1962;181:105-112.

Caffey J. The First Annual Neuhauser Presidential Address of the Society for Pediatric Radiology. Am J. Roentgenol. 1972;114:217-229.

Hobbs CJ, Wynne JM. Physical Signs of Child Abuse. W.B. Saunders. 2001.

Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:463-470.

Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa

June 6, 2005