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Dental care for children with liver disease by Julie Mitchell, Consultant in Paediatric Dentistry

Whilst good dental health is a priority for any parent, for those who have children with liver disease it is a particular concern. Children may be at increased risk of tooth decay if on a high calorie (high sugar) diet. In addition children may suffer from dental problems related to their liver disease.

These include:
– Tooth staining
– Enamel hypoplasia (poorly formed enamel)
– Drug induced gum overgrowth
– Delay in teeth coming through (erupting)

Tooth staining

Teeth forming whilst a child is unwell with liver disease can have:
1- Permanent grey-green staining
2- Enamel Hypoplasia (teeth can have yellow-white patches, easily wear or sometimes be small and misshapen)

The grey-green stain is permanent and is caused by biliverdin (a green pigment made when haemogloblin is broken down) being added into the forming tooth. Adult teeth begin to develop at birth, and from this time until around three years of age all the front teeth and the four back adult teeth are forming. Only the part of the tooth forming at the time a child has liver disease and jaundice will be permanently stained. Once the liver condition has been treated successfully teeth continue to develop normally without staining. These stains cannot be removed with tooth brushing.

What can be done to improve the appearance of these teeth?

Whilst very little treatment can be carried out for baby teeth, a paediatric dentist can carry out a variety of treatment for adult teeth to make the staining less noticeable. This may include tooth whitening (bleaching), placing a white filling to cover the staining (composite masking) or a combination of techniques.

Tooth whitening (bleaching)
This treatment uses a mild bleaching gel inside a specially made mouth guard at night time. This can be a long process and in some cases takes six months or longer. Although the staining improves it is often not possible to completely remove it.

Composite masking

In addition to tooth whitening (bleaching) a white filling material (composite) can be used to cover the remaining staining to make it less noticeable. In children and young adults porcelain veneers and crowns should be avoided as both these treatments involve removing healthy tooth tissue (enamel) to make space for the veneer or crown which significantly weakens teeth. Sometimes in adulthood porcelain veneers or crowns are fitted to help improve the appearance of these teeth, but this is always the last treatment of choice.

When can my child have treatment carried out?

It is better to wait until most adult teeth have come through (12 years onwards) to reduce the need for repeating the treatment and to get the best results. However if children are being bullied or are upset by the appearance of their teeth treatment can be started earlier, provided they can cope with it.

Enamel Hypoplasia

The tooth surface (enamel) can be yellow-white, patchy, easily worn and sensitive. These defects are permanent and are likely to be caused by illness temporally upsetting the cells that form enamel (ameloblasts).

What can be done to improve the appearance of these teeth?

Very little treatment can be carried out for front baby teeth but back teeth which begin to come through around the age of 18 months should be protected to stop the surface from wearing away. The type of treatment will depend upon how worn the teeth are and children’s ability to cope with treatment. These can vary from:

  • Plastic coating (Fissure sealant) / Glass Ionomer Cement (temporary sealant)
  • White filling material (Composite) and Fissure sealant
  • Stainless Steel Crown
  • Extraction (if unrestorable /infected).

Adult front teeth
To improve the appearance of your child’s teeth they may require either tooth whitening, a white filling to cover the affected area (composite masking) or a combination of both techniques.

Adult back teeth (first permanent molars)
These teeth begin to come through around the age of six and should be protected to stop sensitivity, prevent tooth decay and wear. The type of treatment will depend upon how worn the teeth are and can vary from plastic coating, white filling material and fissure sealant, stainless steel crown as above or even a gold or cast metal onlay.

If teeth are severely worn or decayed they may need to be removed when children are around age 9-10, which allows space to be closed by other teeth still growing.

Overgrown gums (gingival overgrowth) due to medicines

Some medicines can cause gums to overgrow (gingival overgrowth) in susceptible transplant patients.

What can be done to avoid this happening?
This condition is rarer now as newer medicines such as Tacrolimus and Sirolimus are less likely to cause gingival overgrowth. Good, regular tooth brushing (twice a day) and visiting the dentist for a professional clean can help reduce the risk of this happening. In severe cases the medicines may need to be changed by your child’s doctor or gum surgery (gingivectomy) carried out by a Paediatric dentist or Periodontist (gum specialist).

Delay in teeth coming through (erupting)

Children’s teeth may take longer to come through (up to 22 months). This could be due to illness but no one really knowns the true cause.

What can be done to encourage my child’s baby teeth to come through?
For baby teeth it is recommended that children are seen and monitored by a Paediatric dentist. Teething rings or gentle massage of gums with a tooth brush may help encourage the teeth to come through.

What can be done to encourage my child’s adult teeth to come through?

If adult teeth fail to come through your child may need dental surgery (surgical exposure) to uncover their teeth. This will require careful planning with the dental team (Paediatric dentist, orthodontist and oral surgeon) and your child’s medical team.

How can I keep my child’s teeth healthy?

1. Children should brush their teeth at least twice a day (before bedtime and one other time) with fluoride toothpaste. Adults will need to help brush teeth for children less than 7 years of age.
2. Try to have less sugar and only have sugary food and drink at mealtimes.
3. When your child is ill try to give them only sugar-free medicines.
4. Take your child to visit a dentist to have their teeth checked every 6 months.

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