Introduction 

Smiling serves as a means of personal expression, showing an individual’s happiness. However, imagine feeling self conscious about your smile due to alignment issues or tooth impaction. Well, many people around the world feel insecure about their smile due to premature loss of primary teeth. Premature loss of deciduous teeth, often perceived as a common childhood occurrence with no major effects, has significant implications on the future dentition of a person. While primary teeth are typically viewed as temporary place holders for permanent teeth, the premature loss of baby teeth can remarkably affect the development and growth of permanent teeth. This research paper looks at those effects through a study and analysis. 

Primary teeth, also known as deciduous, children, or baby teeth, play essential roles in the early stages of the structure and function of the human dentition. Serving as placeholders for permanent adult teeth, they are responsible for chewing, speech development, and contribute to the alignment of the permanent teeth. In many cases, permanent teeth are affected negatively due to the primary teeth being exploited. Premature loss of a baby tooth is most commonly caused by cavities. If children do not build habits to stop cavities from forming at a young age, the susceptibility to dental caries, periodontal disease, and subsequent permanent tooth loss escalates significantly when the permanent teeth come in. Premature loss of primary teeth are very common, yet so harmful. In order for people to realize the necessity to prevent premature extractions of primary teeth, individuals need to see the impact it actually has. This study will intend to answer the question: how does the premature loss of primary teeth affect the development and growth of permanent teeth? 

Literary Review

Dental health has become one of the biggest issues in America. The article “Might Oral Health Be the Next Big Thing” by John E. McDonough provides statistics about oral health in America, which is necessary to analyze the disparities among adults with permanent teeth and why they occur. Today, 130 million Americans have no dental coverage, primarily adults. Medicaid is used by 18.8% of the population, but it does not provide dental coverage to 70% of its enrollees. Along with this, most dentists do not accept Medicaid because it pays a fraction of the rates that private insurances or patients with cash will pay. This is especially hard for individuals residing in low socioeconomic communities because Medicaid is the most common type of medical insurance in those areas, resulting in fewer dentists in those regions. Consequently, these access issues cause over 25% of adults over 65 years of age to have lost all their teeth and 60% of children between the ages 5 and 17 to be affected by cavities. This information is useful to know because it allows for growth in the dental industry to find ways of decreasing oral diseases for those who do not have dental coverage. Premature loss of a primary tooth could foreshadow bad oral hygiene as an adult because if a person does not build brushing and flossing habits at a young age, they could suffer from further decay. Deciduous loss is also more likely to be prominent in patients with Medicaid because of the lack of dentists who accept Medicaid. 

A similar study done by Kenneth Hudson, Jean Stockard, Zach Ramberg analyzes dental health in African Americans and Mexican Americans versus White Americans in the article “The Impact of Socioeconomic Status and Race-Ethnicity on Dental Health.” In their studies, they used the most common way of measuring dental health: counts of decayed or missing teeth. Three measures of health related behaviors were also analyzed: if a person was currently smoking, alcoholic intake measured by beverages per month, and sugar consumption measured by the number of sweets consumed per month. Dental care was also measured by if a participant saw the dentist at least once a year. The results of their analysis indicate a strong difference in dental health. The numbers of DS (decayed surfaces) and MS (missing surfaces) were substantially higher in African Americans and Mexican Americans than in white Americans. Among those younger than 65, Black Americans had the highest level of dental diseases. For participants younger than 65, whites have the fewest number of DS and MS, while blacks obtained the most. Connecting this to the article above, extracting teeth is a lot cheaper than trying to do treatment on it, which is why MS is a lot higher in African and Mexican Americans where Medicaid is common. These results pave the way for further research to figure out ways of making the racial disparities decrease, and allow for this research study to find the early causes of this. If minorities have higher percentages of decayed teeth and missing teeth, they likely have a higher percentage of prematurely losing a primary tooth as well. Sung Eun Choi and Joel White analyzed tooth loss in children and its correlation to race. They found that Black and Hispanic children, aged 6-10 years old, had a higher risk of tooth decay and loss. These disparities could be explained by insurance type and dental procedure types among children. 

Given the significance of the imbalance found in the three journal articles concerning adults with limited access to dental care and racial backgrounds, this research study attempts to go further into these factors by elucidating the repercussions of inadequate dental care for primary or “temporary” teeth and premature extractions. This effectively allows for this research to see if children are affected by these access issues as much as adults, especially when they have their primary teeth. Many might say that the access to the dentist is more vital for adults because children’s teeth will fall out at some point, but this may not be the case. 

It is important to analyze children’s perception of oral health to see how they perceive their own teeth. “Child and Adolescent Perceptions of Oral Health Over the Life Course” analyzes those insights. In this study, the results explained that child and adult characteristics are important determinants of overall health due to cultural influences and the social environment. The article was written after performing a study on a focus group to see different attitudes and feelings towards oral health. The first phase of the study involved four focus groups: two with children 8 - 12 years old, and two with adolescents 13 - 17 years old. The first two groups had a mix of permanent and baby teeth, while the other two groups all had permanent teeth. 64% of the children in focus groups in higher income communities were white and 7% latino. Issues analyzed in their survey included understanding the value of maintaining good oral health over a life course, positive association between maintaining good oral health and interpersonal relationships, and knowledge of the benefits of orthodontics. School aged children viewed their teeth as important in talking, eating and smiling. Adolescents viewed their teeth as important in dating and other relationships. In terms of lifelong oral health, children believed living a longer life as a result of oral self care. Adolescents viewed self care as a way to satisfaction. This article is vital to investigating self care for primary teeth because if children do not view their teeth as important, they are more likely to lack the dental habits needed to have good oral health. 

In addition to the sources above, the article, “Child Indicators: Dental Health,” written by Eugene M. Lewit and Nancy Kerrebrock effectively hit on the key reasons why maintaining good dental health in children is important. Good dental health prevents pain in children and more importantly, prevents tooth loss which affects how the jaw grows and function of teeth. Also, unhealthy teeth such as missing teeth, yellow teeth, and bad positioning of teeth is unattractive, especially when trying to make relationships with others. The authors explained that to many individuals, maintaining good dental health seemed easy among children: consistently brushing, flossing, fluoride usage, good nutrition, and two visits to the dentist per year. However many young children suffer cavities, swollen gums, and pain for bad positioned teeth. One statistic that was interesting was that by age 17, 80% of people will have experienced at least one type of tooth decay. Poor children are less probable than their wealthier peers to visit the dentist, leading to higher risk of suffering from untreated dental diseases. Race also plays a role in children’s dental health. Blacks and Mexicans have more than twice the percentage of untreated cavities than whites. One reason that white children receive more dental care is that whites are more likely to have private dental insurance coverage. In a NHIS survey, it conveyed that those with private dental insurance saw the dentist more than three times a year, compared to those without visiting the dentist less than twice a year. There is a shortage of dentists who accept Medicaid patients. This is a major reason why poor children receive less dental care. From this data, it allows me to go deeper into this study and inspect it though baby teeth, specifically premature loss of baby teeth. 

The article, “The Effect of Thumb and Finger Sucking on Primary Teeth,” analyzes the impact of thumb sucking on the placement of primary teeth. The conductor of the study, Samuel Lewis, studied over thirty children with a history of thumb sucking. All but two babies had started sucking their thumb during the nursing period. Lewis found that deformities start to develop from thumb sucking, the main one being a forward displacement of the upper front teeth. If the right thumb is sucked, the displacement is towards the right, and the opposite for the left thumb. A full correction of the deformity takes about a year and a half. A result seen from the study was that if a child continued to thumb suck even after they broke the habit and a correction occurred, their permanent teeth would be pushed out of place similar to the primary teeth. This article examines the impact of thumb sucking on primary teeth, which helps guide this study, but the study in the article never explicitly explains the impact it has on the placement of permanent teeth after they have come in. 

Nextly, habits are best to develop at a young age because individuals will have the reinforcement they need from a young age. This has direct correlation to dental health; a person who matures with these habits already engraved in them, will more likely have better dental health when they reach adulthood. WILEY published a book called “Child Development” and in this book, there  was a section where R.C. Willett articulated on primary teeth. In this article called “Care of Primary Teeth,” Willett explains how because of the name “temporary teeth,” most people feel that it is not important to take care of them. Defects in your primary teeth when they first erupt are extremely rare, but the chances are 90 to 1 that a child with an American diet will have some sort of disease by the age of four. A lot of this is the parent’s duty because children have not attained the necessary habits to have personal care for their teeth, such as brushing teeth and rinsing their mouths. This source explains the importance of caring for primary teeth, but does not connect it to the later stages. 

Lastly, premature loss of teeth is a major issue in children around the world. There are many factors that lead to a primary tooth being extracted prematurely. The article “Premature Loss of Deciduous Teeth as a Symptom of Systemic Disease: A Narrative Literature Review” thoroughly explains the reasons and consequences of premature extractions in young aged children. This article was constructed by analyzing 196 scientific studies, making it a credible source to identify the need for extractions of baby teeth. After analyzing these studies, the author found many reasons for premature loss and consequences of the tooth loss. The author found mechanisms of premature removal to all be correlated with periodontitis or defective development of tooth cementum. Periodontal breakdown is a vital issue because when the tissue removal and regeneration is not balanced, there is no treatment to stop it. Consequently, the tooth is forced to be removed. Furthermore, the article above is not a research study as it only collects data already researched. This paper will address the issue of premature loss of primary teeth by researching the problem through experimentation. This article was very helpful to this study because it explained the reasons for premature loss, and this inquiry study will examine these reasons on real patients who have had extractions.

Research in the dental field of study is a lot about adults, and when they do examine children, they often overlook the significance of primary teeth as crucial determinants in maintaining good oral health into adulthood with permanent teeth. The article “Care for Primary Teeth” went into detail why primary teeth were important, but never connected it to how it affects their permanent teeth as adults or adolescents. The article “The Effect of Thumb and Finger Sucking on Primary Teeth” analyzes the impact of thumb sucking on the placement of primary teeth, but does not connect these effects to permanent teeth growth after the primary teeth fall out. These allow for another effect on primary teeth to be studied, which is premature loss. Since most studies do not effectively analyze the correlation of premature loss and permanent teeth development, this leaves a major gap in which this study will provide the effects and analysis of those patterns. 

 Methodology

The objective of this experiment is to investigate the various effects premature loss of primary teeth have on permanent teeth. Before starting the study, the researcher’s hypothesis was that most children who have prematurely lost a primary tooth suffer from bad oral health and hygiene. This is because the primary reason for early extraction of baby teeth is due to cavities and decay. The researcher hypothesized that if children lack good oral hygiene when they have primary teeth, cavities will form and infect the gums. Weak tooth enamel makes teeth more vulnerable to decay and cavities, so the researcher hypothesized that if there is a cavity on a primary tooth, the permanent tooth will have a weaker enamel before it fully develops. Therefore, people would be more prone to cavities later in life as well. Secondly, premature loss of primary teeth affect the placement of permanent teeth by not leaving enough room for the bigger permanent teeth to come down, especially when they are lost prematurely. Consequently, the permanent teeth are poorly positioned, leaving the need for braces to rearrange the teeth. 

Content analysis was chosen to examine panoramic x-rays and clinical pictures of children with premature loss of a primary tooth and those same children’s permanent teeth. This would reveal patterns of how the teeth are placed and if they are significantly affected by premature extractions. Experimental research was also conducted as children were placed into groups based on which tooth was extracted. Grouping allowed the researcher to systematically look at the specific factor to see the extent in which it caused affects on permanent teeth. Other groups were hard to create because many of the patients saw another dentist to get their cavities removed before coming to the orthodontist. 

A study which used a similar method was done by Samuel J. Lewis in the article, “The Effect of Thumb and Finger Sucking on the Primary Teeth and Dental Arches.” In this experiment, the researcher looked over models and x-rays of multiple children who had the habit of thumb sucking. The researcher analyzed the models to see if thumb sucking caused deformities in the teeth and arch. He noticed that thumb sucking caused a forward displacement of the upper front teeth. This study demonstrated the proficiency of examining x-rays and clinical images, highlighting the reliability of comparing and contrasting x-rays. 

X-rays are captured from various angles to obtain a comprehensive view of a specific section of the mouth. This enables the dentist to observe changes in the bite over a period of time. Also, dentists often make models from the x-rays to show their patients. In this experiment, the researcher was able to take these x-rays and analyze them thoroughly. In this particular study, panoramic x-rays were utilized, which are two-dimensional dental x-ray examinations that capture the entire mouth in a single image, including the teeth, upper and lower jaws, surrounding structures, and tissues. This analysis proves beneficial as it not only depicts the formation of the tooth, but also precisely identifies the location of any cavities within the gums. In the x-rays, it shows the full picture of permanent teeth coming into contact with the primary teeth. The x-rays show the open spaces caused from missing deciduous tooth after being extracted. 

To measure the effects of premature loss on permanent teeth, the study was conducted at a local dental office in southern California. Data gathered from a dental facility is always retained and augmented over time, making it easy to access the data and analyze the accumulated information. This allowed the researcher to investigate the x-rays that were kept from when children had primary teeth, and compare them to the children’s permanent teeth development with the premature loss of a primary tooth. An orthodontic office was chosen because the x-rays show the mispositioned teeth before braces were placed on the teeth. Most of the children that prematurely lost their teeth did not go back to the dentist for some time; therefore, allowing the rest of their teeth to shift and close the gap of the missing tooth. This could prove highly problematic in the future when the permanent teeth need to come in. The x-rays revealed insufficient space for the incoming permanent teeth. 

Firstly, children were placed into groups based on which tooth was extracted. Creating groups proved beneficial as it distinctly illustrated the correlation and causation between the component and its consequential effects. If most of the children lost the same type of tooth, this could create a new research study later to explain why. Secondly, the researcher looked at over 150 x-rays to see which ones were viable for this particular study. Most of the x-rays that showed crowding were because of genetics such as smaller jaw size paired with large permanent teeth. About 11 x-rays worked, as they all showed mispositioned permanent teeth due to premature removal of a primary tooth. 

Limitations

Before looking at the results of the study, it is important to understand the limitations of the study and the effects they will have. The most significant limitation was that all the patients used in the study were from a high income family. According to a study done by multiple high level research professors and dentists in the article, “Wealth Effect And Dental Care Utilization In The US,” they found that both wealth and income each have a strong and independent positive effect on dental care use. On average, this would mean that the patients that participated in this study are most likely going to have better oral hygiene and health because they have the access to sufficient dentists. The researcher wanted to examine both affluent children and poor children to see if that had a direct correlation to deciduous loss, but was unable to find enough low income children. This is also connected to insurance types as all the patients had private insurances and not Medicare. Because of this, the researcher was not able to look at insurance types as an independent variable in this study. Another limitation is that all of the participants visited a dentist before coming to the orthodontist. The patients had to be cavity-free before coming to the orthodontist because orthodontists do not deal with cavities or decay. Even though all the patients had cavities, which is the underlying reason why they all had premature loss of a primary tooth, this affected the x-rays used in the study. This affected the study because the x-rays did not show cavities in the patients. This would have made it easier to see the location of the decay and premature loss because the cavities could have been easily detected. 

Findings

After gathering all the data needed for this study, the researcher analyzed it and organized it based on which tooth was removed. From the ten clinical x-rays depicting premature loss of a tooth, the most common was the canine cuspid accounting for seven of the ten. The remaining three cases involved molars. Upon data analysis, genetics were found to be a significant independent factor. Certain x-rays revealed smaller teeth, while others exhibited bigger teeth due to their genes. This disparity impacts placement, as most primary teeth are similarly sized, but permanent teeth vary in size.

Figure 1. Primary teeth C, M, and R were prematurely removed causing permanent teeth #6, #22, and #27 to be impacted is shown above. An expander has been placed to expand the jaw for room to be created for the permanent teeth to come in. 

The first patient analyzed had three canines prematurely extracted. This caused an immense shift in his dentition. An expander was needed due to the impaction of his three permanent canines which were going to replace his primary canines that are blocked out from surfacing. The researcher decided this was a good x-ray to present because it shows the need for treatment to be done when baby teeth are removed at a young age. 

Figure 2. Primary tooth T was prematurely lost causing permanent tooth #29 to be blocked out from surfacing is shown above. 

Figure 3. Primary teeth L and T were prematurely extracted as shown above. This caused permanent teeth #21 and #29 to be impacted. 

Figure 2 and figure 3 are examples of premature loss of molars. Molars are another common tooth type that will be extracted prematurely because they are the teeth used for chewing. These two patients had cavities form around their molars most likely due to high consumption of sugar. Sugar consumption is very high for children, which is why this is a good example of the lasting effects sugar has on oral health. If these patients sufficiently brushed, premature loss of their molars would never have been an issue. The patient in figure 3 did not wait too long before seeing another dentist to have treatment done, which is why the space did not fully close. 

Figure 4. Primary canines C and M were extracted early as shown above. This caused #6 and #22 to be severely impacted. 

This patient was affected by his extraction the most. When canine #6 was blocked, the root got so long it started to go into the bone of the jaw. The root could not grow anymore and it melted the root of the adult incisor and it had to be taken out. Now, this patient does not have an incisor, which is a vital tooth because of its frontal location in the dentition. 

Discussion

The purpose of this study was to answer the question, how does the premature loss of primary teeth affect the growth of permanent teeth? This study analyzed whether premature loss had a significant effect on the dentition through the examination of x-rays. After completing the study, the researcher found several effects that premature extraction has on the development of the permanent teeth arrangement; alignment issues, impaction, delayed eruption, and functional problems such as chewing. Firstly and most importantly, alignment issues were seen in every x-ray that dealt with premature removal of a baby tooth. Severe alignment issues are mostly due to malocclusions which are hereditary, but these ten patients portrayed it because of early extraction. The most common tooth was the canine cuspid being removed and hitting the neighboring lateral incisor as seen in figures 1, 4, 5, 6, 7, 9, 10. The other three patient cases involved the extraction of molars (Figure 2, 3, 8). Molars and canines are used for chewing and biting foods, which is why they are the teeth being prematurely removed, and not laterals or incisors. These types of teeth are most susceptible to cavities, and the formation of decay can frequently result in extraction.

Secondly, impaction and delayed eruption are consequences of premature removal. All the patients showed impaction around the area of premature loss. Figure 4 is a clear illustration of impaction and delayed eruption, with three teeth trying to fit into two slots. Following the premature extraction of cuspid #6, the space gradually closed overtime. Despite the space closing up, the canine still needed to erupt, but lacked enough room to do so. Consequently, the root of the permanent canine grew so long that it penetrated the jaw bone. Not only was it painful, but the permanent incisor had to be extracted as well because the canine could not grow any longer. This patient experienced a case resulting in delayed canine eruption and permanent tooth loss, which will not grow back. Furthermore, figure 4 conveys the severe impacts of removing a tooth prematurely. Even though figure 4 is a severe occurrence of premature loss, the rest of the cases have impaction and delayed eruption as well. 

Moreover, the only way to fix these malocclusions is through the intense use of orthodontic treatment. According to several pediatric dentists, the main treatment option for crowing and similar oral problems is braces. These dentists also state that aligners and retainers are also viable options. Premature loss of teeth can have such a lasting effect later because overtime the gap for the tooth gradually closes. This means that when it is time for orthodontic treatment, the gap has to be reopened, usually expanders or other devices are used as seen in figure 1. In figure 1, the expander opens up room between the teeth and enlarges the palate to allow the canine to erupt. Once the canine erupts, braces can be placed on the teeth to improve the alignment of the dentition. 

Subsequently, another takeaway after analyzing the x-rays is the type of tooth and its effect. Canine cuspids are the sharper teeth which break and tear food. Molars are the teeth used for chewing and grinding food. Because all of the teeth that were extracted were canines, it proved that the diet of these children helped cause their premature loss. Sugar and other harmful bacteria get easily stuck to canines because they are biting into the food. Therefore, cavities will form from not brushing the bacteria off the teeth. This conveys that all the patients had bad oral hygiene and most likely a diet with a high sugar intake.  

Conclusion

A common misconception that adults have is, taking care of primary teeth is not as vital as permanent teeth because baby teeth fall out at some point. However, this mindset is flawed as evidently proved by this research study. Neglecting primary teeth can lead to decay, which is the main cause of premature loss of a tooth. The various consequences of prematurely removing a primary tooth have already been stated.  Additionally, a study that supports this claim was done by several pediatric dentists in the article, “Evaluation of knowledge and attitude of parents about the importance of maintaining primary dentition - A cross-sectional study.” In this study, they conducted a survey in which 100 parents were questioned about their children’s oral health. The results showed that approximately 68% of the parents thought that treatment of primary teeth was not necessary as they would eventually fall out. This could mean that parents will not be as strict about brushing or even visiting the dentist frequently. In order to decrease the amount of premature extractions due to cavities and decay, parents have to be informed of the problems their children could face. An increase in parental knowledge would encourage parents to provide better dental care for their children. This allows for another research inquiry to be studied; How can parents enhance their knowledge and understanding of oral health to ensure better dental care for their children?

Nextly, another takeaway from this study is causes and prevention of premature removal of primary teeth. In my study all the patients initially had cavities which led to premature loss of a baby canine or molar. The School of Dentistry at the University of Cuenca determines the central causes of premature loss in the journal article, “Causes of premature loss of primary teeth and frequency of the utilization of space maintainers in children aged 6-8 years.” The study performed in this article examined children in the recent years of 2019-2022. This makes it relevant to the time of this research study. The results showed that dental caries and cavities were the main causes of deciduous tooth loss. After conducting this study and reading several sources on the causes of primary tooth loss, it is evident that preventing cavities is urgent. Cavities could be caused by numerous factors, so in order to limit the chances of cavities forming, hygiene habits and a better diet should be enforced. A healthier diet means reducing consumption of sugary beverages and foods. Poor dietary habits paired with inadequate oral hygiene contribute to the highest incidence of cavities. According to an article in the National Library of Medicine, it illustrates percentages of sugar intake from 1977 to 2012. The article stated that the percentage of the total energy intake from added sugars should be about 10%. In 1977, children consumed 14% of their total energy from added sugar. In 2003, 18% and 17% in 2012. Even though the percent intake of sugar decreased from 2003 to 2012, it is still way above the recommended 10%. From reviewing this and this study, it can be concluded that healthier diets are needed to prevent cavities, which will prevent deciduous tooth loss. Another research topic that stems from this is, how can children decrease their intake of sugary foods and drinks to lower the risk of dental caries and cavities?

Furthermore, the significance of this project is immense. This research study presented many cases of patients who prematurely lost a baby tooth due to cavities. This study sets the path for many new studies to look into variables and outcomes from this study such as prevention of cavities through better dietary habits.

Bibliography

Admin. 2021. “Crowded Teeth in Children.” KidzVil Pediatric Dentistry. September 1, 2021. kidzvildental.com/crowded-teeth-in-children/#:~:text=Common%20treatment%20options%20for%20overcrowding.

Cárdenas H, Dayana Estefania Nivelo Tenesaca , Jessenia Katherine Pinargote Clavijo , Milton Rivaldo Valencia Arteaga , Karen Anais Urgiles Espinoza  and Maria Yolanda Yunga Picón. Causes of premature loss of primary teeth and frequency of the utilization of space maintainers in children aged 6-8 years attending the School of Dentistry at the University of Cuenca during the period 2019-2022 World Journal of Advanced Research and Reviews, 2023, 19(01), 168–173 (4 July 2023) wjarr.com/sites/default/files/WJARR-2023-1284.pdf

Choi SE, White J, Mertz E, Normand SL. Analysis of Race and Ethnicity, Socioeconomic Factors, and Tooth Decay Among US Children. JAMA Netw Open. 2023 June 1;6(6) pubmed.ncbi.nlm.nih.gov/37318807/#:~:text=For%20children%20aged%206%20to,1.18)%20compared%20with%20White%20children.

Hudson K, Stockard J, Ramberg Z. (n.d.). The Impact of Socioeconomic Status and Race-Ethnicity on Dental Health. Sociological Perspectives, Vol. 50, No. 1 (Spring 2007), Pp. 7-25 (20 Pages). jstor.org/stable/10.1525/sop.2007.50..7

Lewit E, Kerrebrock N, Child Indicators: Dental Health. (n.d.). The Future of Children, Vol. 8, No. 1, Protecting Children From Abuse and Neglect (Spring, 1998), Pp. 133-142 (10 Pages). jstor.org/stable/1602633

Lewis J. “The Effect of Thumb and Finger Sucking on the Primary Teeth and Dental Arches” Child Development, Vol. 8, No. 1 (Mar., 1937), pp. 93-98 (6 pages) jstor.org/stable/1125827

Manski RJ, Moeller JF, Chen H, St Clair PA, Schimmel J, Pepper JV. Wealth effect and dental care utilization in the United States. J Public Health Dent. 2012 Summer;72(3):179-89. doi: 10.1111/j.1752-7325.2012.00312.x. Epub 2012 Apr 20. PMID: 22515635; PMCID: PMC3433846. ncbi.nlm.nih.gov/pmc/articles/PMC3433846/

Maida C, Marcus M, Hays, Coulter I, Ramos-Gomez G, Y. Lee S, S. McClory P, Van L, Yan Wang, Jie Shen, Li Cai, Spolsky V, J. Crall J, Honghu Liu. Child and adolescent perceptions of oral health over the life course “Quality of Life Research,” Vol. 24, No. 11 (November 2015), pp. 2739-2751 (13 pages) jstor.org/stable/44849377

McDonough J. Might Oral Health Be the Next Big Thing?, The Milbank Quarterly, Vol. 94, No. 4 (December 2016), pp. 720-723 (4 pages) jstor.org/stable/24869203

Powell ES, Smith-Taillie LP, Popkin BM. Added Sugars Intake Across the Distribution of US Children and Adult Consumers: 1977-2012. J Acad Nutr Diet. 2016 Oct;116(10):1543-1550.e1. doi: 10.1016/j.jand.2016.06.003. Epub 2016 Aug 1. PMID: 27492320; PMCID: PMC5039079. ncbi.nlm.nih.gov/pmc/articles/PMC5039079/#:~:text=For%20children%2C%20added%20sugars%20consumed,not%20significantly%20decline%20after%202003.

Ramakrishnan M, Banu S, Ningthoujam S, Samuel VA. Evaluation of knowledge and attitude of parents about the importance of maintaining primary dentition - A cross-sectional study. J Family Med Prim Care. 2019 Feb;8(2):414-418. doi: 10.4103/jfmpc.jfmpc_371_18. PMID: 30984647; PMCID: PMC6436316. ncbi.nlm.nih.gov/pmc/articles/PMC6436316/

Spodzieja K, Olczak-Kowalczyk D. Premature Loss of Deciduous Teeth as a Symptom of Systemic Disease: A Narrative Literature Review. Int J Environ Res Public Health. 2022 Mar 13;19(6):3386. doi: 10.3390/ijerph19063386. PMID: 35329073; PMCID: PMC8953685. ncbi.nlm.nih.gov/pmc/articles/PMC8953685/

Willett R.C. Care of Primary Teeth, Child Development, Vol. 7, No. 4 (Dec., 1936), pp. 273-275 (3 pages) jstor.org/stable/1125579

APPENDIX

Figure 5. Tooth M was lost prematurely as shown above. This caused the canine #22 to be impacted. This case was left untreated for some time, resulting in the gap for the permanent tooth to disappear. 

Figure 6. Primary tooth M was lost prematurely causing canine tooth #22 to be impacted. This patient's bottom lateral incisor is completely positioned wrong, blocking out his canine. This case needs severe orthodontic treatment.

Figure 7. Primary teeth C and R were prematurely removed as shown above. The premature removal of these teeth cause permanent teeth #6 and #27 to be impacted. 

Figure 8. Primary tooth S was prematurely extracted as shown above. This cause the permanent molar #28 to be impacted. 

Figure 9. Primary teeth C and M were prematurely removed causing canines #6 and #22 to be impacted. 

Figure 10. Primary tooth R was prematurely removed causing permanent tooth #27 to be severely impacted.