A 5-year-old male came to clinic for his health supervision examination. He and his family had no concerns, but did want to know when they could expect that his primary teeth would fall out.
He saw a dentist regularly and brushed his teeth regularly with fluoride toothpaste. There was fluoride in the community water supply.
The pertinent physical exam revealed a healthy male with normal growth parameters. He had 20 deciduous teeth with no obvious caries or gum problems.
The diagnosis of healthy male was made. The family was counseled that the exfoliation of primary teeth usually begins between 6-7 years of age.
The health care provider recommended continuing brushing, seeing the dentist and also mouthguards for sports.
Dental health is an important part of a patient’s overall health and should be screened for during health supervision visits.
Patients and parents often have questions about timing of eruption or exfoliation, numbers of teeth and tooth coloring.
See a previous PediatricEducation.org case about abnormally colored teeth.
The American Dental Association has tooth eruption and exfoliation charts.
Eruption of primary (i.e. deciduous) teeth
Eruption of primary teeth is considered normal if it occurs within 6 months of the expected eruption time.
Eruption usually occurs in the anterior aspect of the mouth first and follows posteriorly.
The lower central incisor is usually the first tooth erupted at 6-10 months of age.
The upper central incisors usually follow at 8-12 months of age.
The upper central second molar is usually the last tooth erupted at 25-33 months of age.
Newborn infants may have natal teeth. They may be supernumerary (i.e. extra teeth) or true primary dentitia. They are generally left in place unless they are very loose and a potential choking hazard, or if they interfere with feeding.
They can be pulled but may leave a defect until the permanent teeth erupt.
Eruption of permanent teeth
Exfoliation of primary teeth and eruption of secondary teeth follows a similar anterior to posterior pattern.
There is often a year time period (or more) between exfoliation and eruption of the permanent teeth.
Central incisors (upper and lower) exfoliate at 6-7 years and erupt at 7-8 years of age.
Third molars, or wisdom teeth, generally erupt at 17-21 years of age.
Causes of delayed eruption of primary and permanent teeth includes numerous systemic and congenital syndromes including Apert syndrome, De Lange syndrome, Down syndrome, Hypothyroidism, and Osteogenesis imperfecta.
Causes of delayed exfoliation of primary teeth usually are idiopathic, but a dental evaluation should be performed.
Causes of hypodontia (i.e. too few teeth) again are often congenital including Achrondroplasia, Cleft lip +/- palate, Crouzon syndrome, Down syndrome, Ectodermal dysplasia, and Ehler-Danlos syndrome.
Causes of hyperdontia (i.e. too many teeth) are often seen in families and can be associated with Cleft lip +/- palate, Crouzon syndrome, Down syndrome, and Sturge-Weber syndrome.
Questions for Further Discussion
1. What are the recommendations for the timing of the first dental visit?
2. What is the primary health care provider’s role in the treatment of dental trauma?
3. What are the indications for third molar removal?
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 MedlinePlus for these topics: Child Dental Health and Tooth Disorders
and at Pediatric Common Questions, Quick Answers for this topic: Dental Care
To view current news articles on this topic check Google News.
Casamassimo P. 1996. Bright Futures in Practice: Oral Health. Arlington, VA: National Center for Education
in Maternal and Child Health. Available from the Internet at http://www.brightfutures.org/oralhealth/pdf/index.html (cited 8/14/06).
Rudolph CD, et.al. Rudolph’s Pediatrics. 21st edit. McGraw-Hill, New York, NY. 2003:88, 1286-1287.
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effecively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
September 5, 2006