by Martha Ann Keels, D.D.S., Ph.D.
Constipation and dental caries may sound like
strange bedfellows, but there is a connection.
Seventeen to 40% of children experience constipation. Symptoms such as painful defecation, fecal
incontinence and abdominal pain can contribute to
significant distress for both the child and family. The
desire for immediate relief may lead families to try
home remedies, many of which are known to cause
In one week, two pediatric patients presented to a
dental clinic with a mouthful of cavities. Both children were healthy with the exception of a history of
chronic constipation. Both children were following an
elder relative’s recommendation to drink a sugar syrup
several times a day along with juice and were snacking
frequently on dried fruit and fiber gummies.
The etiology of dental caries is multifactorial with
frequent consumption of carbohydrates being a histor-
ically strong and consistent risk factor. Brushing twice
a day and flossing once a day may not be sufficient to
overcome the high amounts of sugar some children are
consuming to treat chronic constipation.
Evidence-based guidelines for the evaluation and
treatment of functional constipation were updated
in 2013 by the North American Society for Pediat-
ric Gastroenterology, Hepatology and Nutrition and
the European Society for Pediatric Gastroenterology,
Hepatology and Nutrition. The guidelines state that
scientific evidence does not support the use of fiber
supplements, probiotics, extra fluid intake, increased
physical activity, behavioral therapy or biofeedback for
the treatment of constipation in children.
The most effective and safest pharmacologic treat-
ment is polyethylene glycol (PEG). If PEG is not avail-
able, then lactulose is recommended. Both PEG and
lactulose are less cariogenic than alternative remedies.
Constipation is among many medical conditions
that benefit from collaborative care between primary
health care providers and the dental team.
The pediatric dentist can make the child’s pediatri-
cian aware of the chronic constipation problem and
any home remedies being used. Encouraging the family
to see the pediatrician for proper evaluation and man-
agement of constipation is as important as urging care
for conditions like cow’s milk allergy, celiac disease,
hypothyroidism and hypercalcemia.
In addition, pediatricians can provide successful ev-
idence-based “non-cariogenic” treatment regimens for
constipation. If a cariogenic remedy has to be used,
it would be prudent to ensure the child has a dental
home and educate the family that frequently eating
cariogenic foods may increase the risk of dental caries.
A common electronic health record (EHR) between
physicians and dentists is one tool to facilitate care coordination and optimize health outcomes for children.
Adding an alert in the EHR for patient education when
a medical therapy might carry a risk for developing
dental caries would be a value-added preventive benefit.
Dr. Keels is a member of the AAP Section
on Oral Health.
Those who remember learning pliés and pirouettes
may not be fazed when an injured dancer presents for
care. However, most pediatric providers are uncertain
how to approach these uber-flexible patients who also
have aesthetic components to their activity.
Having knowledge of common injuries and whether
the dancer can modify activity during recovery is beneficial for providers and patients.
There are a variety of dance forms, including ballet,
tap, jazz, modern, contemporary, Irish and hula, each
with various injury patterns. At least 50% of pediatric
and adolescent dancers will experience an injury.
The most common acute injury is an ankle sprain.
The most common chronic injuries involve the lower
extremities and back. It seems that back injuries and
ankle/foot injuries are more common in younger dancers, whereas knee injuries tend to increase as dancers
As with all athletes, dancers will compensate for any
areas of weakness to continue to perform, but eventually will sustain overuse injuries. Tendinopathy/overuse
injury also has been related to excessive fatigue and
insufficient warm-up, both of which are modifiable
One other important condition to always keep in
mind is the female athlete triad. Aesthetic demands
place dancers at higher risk for the triad, including
constant perfecting of movements in front of mirrors,
allowing for body self-criticism and often unfair comparison to others in the class. (See the AAP clinical
report The Female Athlete Triad at http://pediatrics.
Taking a history
It is important to know the intensity of the dancer’s upcoming schedule, hours per week of activity,
upcoming performances/competitions, and level and
type of dance. Obtaining this information will help
build rapport with the dancer. The remaining historical questions are similar to those asked of any other
If the dancer has an acute injury, then reviewing the
mechanism of injury is essential. If the injury is chronic, it is important to note any alterations in the amount
of time spent dancing, technique, flooring or shoes.
The majority of injured dancers told simply to stop
dancing by a provider will stop seeking medical advice.
However, avoiding portions of class that reproduce
symptoms often is well-accepted.
Treatment of most chronic injuries will include
a period of modified rest and therapeutic exercises to balance strength and stability. If the dancer
prefers formal physical therapy, it is essential that
the therapist has experience with dancers and their
Acute injuries typically are treated the same as
any other athlete, but progressive return for ballet
may start sooner as dancers potentially can take
most of class with nonweight-bearing movements.
Communication with instructors will clarify parameters of participation.
Ensuring plenty of sleep, hydration and warm-up prior to class will help with injury recovery but
also should be part of anticipatory guidance during
health maintenance visits.
Older ballet dancers may want to know when
they can go en pointe, a classical ballet technique
in which dancers support their body weight on
the tips of the toes while wearing pointe shoes.
For pointe readiness, a dancer must have been taking
ballet class twice a week for a minimum of three years
and must have adequate strength and technique. The
average age of pointe readiness is 12.
For providers who have not had opportunities to
take or observe dance classes, You Tube videos on some
typical dance routines make it easy to get a sense of
the rigors and expectations of dance and provide the
knowledge to better evaluate key movements and mechanics in the office. Visualizing the end goal after
recovery also will help providers guide patients to reach
Drs. King and Koutures are members of the AAP Council
on Sports Medicine and Fitness.
Injuries among dancers present unique challenges
‘Remedies’ for constipation may cause dental caries
Knowledge of common injuries sustained by young dancers — and whether the dancer can modify activity during
recovery — can help pediatric professionals better treat