Guideline on Oral Health Care for the Pregnant Adolescent.

Resident’s Name: Jessica Wilson

Program: Lutheran Medical Center - Providence

Article title: Guideline on Oral Health Care for the Pregnant Adolescent.

Author(s): Council on Clinical Affairs, Committee on the Adolescent.

Journal: AAPD Reference Manual.

Year. Volume (number). Page #’s: 2007. 32(6). 127-131.

Major topic: Pregnant Adolescent

Overview of method of research: Clinical Guidelines.

Purpose:
To address the management of oral health care particular to that of the pregnant adolescent.

Methods:
Guideline is based on a review of current literature as well as best clinical practice and expert opinion.

Background:

Although the birth rate for US females decreased 1% from 2003 to 2004, about 900,000 teenagers still become pregnant each year. Additionally 50% of teen pregnancies occur within the first 6 months of initial sexual intercourse and 83% of pregnant teenagers are from low income families. Once an adolescent has given birth to one infant, she is at an increased risk of giving birth to another. Pregnant females between the ages of 11 and 15 are at a higher risk for medical complications.

During pregnancy, nutrients such as folate, vitamin B 6 & 12, calcium and zinc are particularly important. Nausea and vomiting are associated with 50-90% of all pregnancies in the first trimester and are associated with young age and low SES.

The FDA has defined 5 categories of drugs in regard to their safety for use in pregnant women. Category A includes drugs studied on humans and have been shown to be safe for use, category B drugs have shown no evidence of risk, category C drugs may be used with caution (aspirin and aspirin-containing drugs), and categories D and X and not intended for use during pregnancy.

Women who smoke during pregnancy have an increased risk for ectopic pregnancy, spontaneous abortion and preterm delivery. Infants born to mothers that smoke are also likely to be of low birth weight, increased risk of stillbirths, and SIDS as well as possible mental retardation and birth defects such as clefting. The exposure of second hand smoke has been shown to be associated with lower respiratory infections, middle ear infections, asthma, and caries in the primary dentition. Women are more likely to stop smoking during pregnancy during pregnancy than any other time in their lives.

There are several oral conditions associated with pregnancy such as, xerostomia, gingivitis and periodontitis.

One study concluded that most pregnant women do not seek dental care during their pregnancy even though 50% had a problem. The consequences of not treating an active infection during pregnancy outweigh the risks posed by most of the medications required for dental care.

When taking radiographs on a pregnant individual, shielding the thyroid gland as well as the abdomen are of utmost importance as are using high-speed film or digital radiography and avoiding retakes. The juvenile thyroid is one of the most sensitive organs to radiation-induced tumors. This sensitivity decreases with age and almost disappears after the age of 20. The typical dental radiograph rarely if ever uses a measurable absorbed dose to the embryo or fetus.

The safest and most comfortable time to treat a pregnant female is during weeks 14-20. During the last trimester pregnant women have delayed gastric emptying and are therefore at a higher risk for aspiration. Elective dental treatment should be performed during the second trimester and may prevent problems from occurring the third trimester.

Currently there is no evidence supporting adverse effects of existing amalgams on the fetus, but the mercury vapor from placement or removal of amalgam may be inhaled and can cross the placenta. A rubber dam and high speed suction can decrease the exposure to mercury.

Improving oral health during pregnancy which leads to a reduction of SM can reduce the SM in offspring as transmission can occur as early as the first year of life. “Beginning in the sixth month of pregnancy, a daily rinse of 0.05 percent sodium fluoride and 0.12 percent chlorhexadine has resulted in significant reduction in levels of caries-causing bacteria…” Xylitol gum has also been shown to decrease levels of SM; however the frequency, amount and duration are still unclear.

Laws regarding informed consent for underage pregnant females vary from state to state. Some require parental consent, some entitle adolescents to confidentiality regarding their health and pregnancy, and others consider the adolescent to be a “mature minor” and some states emancipate minors who are pregnant. The practitioner should be aware and abide by the laws set by their state.

Recommendations:

AAPD recommends all pregnant adolescents seek professional oral health care during the first trimester. A thorough evaluation including a caries risk assessment tool should be conducted. Radiographs may be indicated. If dental treatment must be deferred until after delivery, so should radiographic evaluation.

Counseling should address:
1. The relationship between maternal health with fetal health (perio disease and preterm birth or preeclampsia)
2. OHI including rinses and xylitol gum to decrease postpartum SM transmission
3. Diet counseling, avoiding frequent exposure to cariogenic foods and beverages
4. Anticipatory guidance for the infant’s oral health including the early establishment of a dental home
5. Anticipatory guidance for the adolescent including injury prevention, oral piercings, tobacco and substance abuse, sealants and third molars
6. Changes in the oral environment secondary to pregnancy (xerostomia and shifts in oral flora)
7. Individualized treatment recommendations for each patient

Preventative services should be of high priority, with a prophy being completed during the first trimester and again during the third trimester. A periodontal referral may be necessary if progressive perio disease exists. The AAPD does not support the use of fluoride supplements to benefit the fetus.

The pregnant adolescent experiencing morning sickness should be advised to rinse with water and sodium bicarbonate and to avoid tooth brushing for approximately 1 hour after vomiting in order to decrease erosion. Fluoride can used to decrease sensitivity and hard tissue loss.
In order to treat xerostomia, patients should increase their water intake and try chewing sugarless gum to stimulate salivation.

Elective restorative and periodontal procedures should be completed during the second trimester. The patient should be aware of benefits, risks and alternatives to amalgam restorations and a rubber dam should be used for the application or removal of amalgam. N2O should be limited and may be contraindicated in the first trimester

Local anesthesia and other medications should be evaluated for benefits versus risks. The provider should use the safest medication, the minimum dosage and limited duration. Aspirin or aspirin-containing products, erythromycin estolate and tetracycline should be avoided.

The provider should be familiar with state statutes that determine consent required for an underage adolescent. When parental consent is required and the parents are unaware of the pregnancy, the adolescent should be encouraged to inform them in order to understand the benefits and risks involved in a procedure.

The pediatric dentist should also use positive youth development (PYD) in interacting with the adolescent as a strong relationship can be influential in improving adolescent oral health and aiding in the transition to adult health care. This can provide a safety net for the adolescent in times of need.

Assessment of Article:
Although a lot of this is common sense and same protocols for any pregnant woman, it was a great review.

Guideline on Periodicity of Examination, Preventative Dental Services, Anticipatory Guidance/Counseling, and Oral Tx for Children, and Adolescents

Resident: Adam J. Bottrill
Date: 16MAR11
Region: Providence
Article title: Guideline on Periodicity of Examination, Preventative Dental Services, Anticipatory Guidance/Counseling, and Oral Tx for Children, and Adolescents
Author(s): Clinical Affairs Committee
Journal: Pediatric Dentistry Reference Manual
Page #s: 93-100
Vol:No Date: 2010
Major topic: Periodicity of various services.
Minor topic(s): None
Type of Article: Guidelines

Main Purpose: This guideline is meant to help practitioners make clinical decisions concerning preventative oral health interventions, including anticipatory guidance and preventative counseling, for infants, children, and adolescents.

Key points in the article discussion:

I. General:

A. The AAPD recommends initiating professional oral health intervention in infancy and continuing through adolescence and beyond.

II. Clinical Oral Examination:

A. Components of a comprehensive oral examination include assessment of:
1. General health, pain, extraoral soft tissue, TMJ, intraoral soft tissue, OH, perio health, intraoral hard tissue, occlusion, caries risk, behavior.
2. 6mo interval is typical however frequency may be increased based on clinical need.

III. Caries Risk Assessment:

A. KEY element of preventative care.
B. Prevention by identifying causative factors and optimizing protective factors.
C. Risk assessment must be repeated regularly due to changes in habits and development of the child.

IV. Prophylaxis and Topical Fluoride Treatment.

A. Many patients lack the skill or motivation to become and remain plaque-free for a significant time.
B. Hormonal changes can effect oral microflora.
C. Caries risk changes with age and eruption pattern.
D. Prophylaxis and fluoride treatment is typically 6mo intervals however each patient must have an individual treatment plan.
1. Moderate risk: every 6mo
2. High risk: more frequent

V. Fluoride Supplementation:

A. The AAPD encourages optimal fluoride exposure for every child, recognizing fluoride in the community water supplies as the most beneficial and inexpensive preventive intervention. Supplementation should be considered when exposure is not optimal. Supplementation should be in accordance with the jointly recommended guidelines of AAPD, AAP, ADA and CDC.... in my opinion, THIS IS A COP-OUT STATEMENT.

VI. Anticipatory Guidance:

A. Thorough discussion should occur at every appointment through the patient's life. This is the only way to properly keep track of the changes in habits and risk factors in order to discourage risky behavior and promote proper oral health.
B. High risk dietary habits begin by 1yo.
C. Include injury-prevention counseling.
D. Non-nutritive sucking habits encouraged to stop by 3yo
E. Speech referals if needed.
F. Smoking and smokeless tobacco use becomes an issue later in childs life.
G. Let's not forget INTRAORAL PIERCINGS! ... bad bad bad

VII. Radiographic Assessment:

A. Timing should not be based on age. Instead review of dental history and full exam.
B. ALARA

VIII. Tx of Disease:

A. Immediate and timely intervention (just like St. Joseph!)

IX. Ts of Malocclusion:

A. Early Tx of malocclusion.
1. Reversing adverse growth
2. Preventing dental and skeletal disharmonies
3. improving aesthetics of the smile
4. improving self image
5. improving occlusion

X. Sealants:

A. Reduce the risk of pit and fissure caries in susceptible teeth and are cost-effective when maintained.

XI. Third Molars:

A. Pan or PA assessment is indicated during late adolescent life. Decision to remove should be made before mid-twenties.

XII. Referral for Regular and Periodic Dental Care:

A. Proper education and transition to an adult dentist. Don't just leave the patient hanging.
B. Until the Pt has found appropriate adult dental care, he/she should maintain relationship with pedo for emergency services.

XIII. Recommendations by Age:






















Assessment of Article: It's the reference Manual. It's the "standard of care". Know it. Love it.

03/16/2011 Guideline on Use of Local Anesthesia (LA) for Pediatric Dental patients

Resident: J. Hencler
Date: 03/16/2011

Author: AAPD
Journal: AAPD Reference Manual V32/NO4 10/11

Major topic: LA
Type of Article: Reference/Review

Main Purpose:
To provide a set of accepted guidelines that will help practitioners make informed decisions when using LA to control pain in infants, children, adolescents, and individuals with special needs during the delivery of oral health care.

Background/Contraindications:
Two types: esters and amides. LAs are vasodilators. Vasoconstrictors added to constrict blood vessels, slow the rate of absorption which lowers risk of toxicity, and prolong the mechanism of action. Epi is contraindicated in patients w/ hyperthyroidism. Its dose should be kept minimal in patients taking tricyclic antidepressants since dysrhythmias may occur. Vasoconstrictors levonordefrin and norepi are absolutely contraindicated in these patients. Patients w/ significant CV disease, thyroid dysfunction, diabetes, or sulfate sensivity and those taking MAO inhibitors, tricyclic antidepressants, or phenothiazines may require med consult to determine need for LA w/out vasoconstrictor. When halogenated gases such as halothane are used for GA, the myocardium is sensitized to epi so use caution w/ use of LA w/ epi. Amide LAs are no longer contraindicated in patients w/ family hx of malignant hypothermia. The inflammatory process of infection inhibits LA mechanism of action due to lowering of pH. Also, inserting needle into active site of infection may lead to spread of infection. Reports of paresthesia are more common w/ articaine and prilocaine. The risk of permanent paresthesia is 1:1,200,000 for 0.5%, 2%, and 3% LAs and 1:500,000 for 4% LAs. Long acting LAs such as bupivicaine are not recommended for children and special needs patients.

Guidelines/Recommendations:
Topical anesthetic may be used to reduce discomfort associated w/ needle penetration. Understand properties of topical anesthetic. A metered spray is suggested is an aerosol preparation is used. Systemic absorption of the drugs in topical anesthetics must be considered when calculation the total amount of anesthetic administered.

Always use aspirating syringes. 23- through 30-gauge needles may be used for intraoral injections, since blood can be aspirated through all of them. Aspiration can be more difficult w/ smaller gauge needles. Needles should not be bent.

Documentation must include type and dosage of LA and vasoconstrictor and may include type of injection, needle selection, and patient response. When LA is administered in conjunction w/ sedative drugs, the doses of all agents must be noted on a time-based record. In patients for whom the max dose of LA may be a concern, the weight should be documented pre-operatively. Document should include post-injection instructions were reviewed with child and parent.

After injection, someone should remain w/ patient while LA takes effect. Most adverse drug reactions develop either during the injection or w/in 5-10 minutes. Overdose of LA can result from accidental intravascular injection (always aspirate) or repeated injections. LA causes a bi-phasic reaction (excitation followed by depression) in the CNS. The CV system response to LA toxicity is also bi-phasic. Allergy to LA is not dose dependent but is due to patient’s capacity to react to even a small dose. True allergy to an amide is very rare. For patients w/ an allergy to bisulfates, use a LA w/out a vasoconstrictor.

Residual soft tissue anesthesia should be minimized in pediatric and special needs patients to decrease risk of self-inflicted post-op injuries. Practitioners should review with parents/caregivers regarding behavioral precautions to reduce self inflicted soft-tissue trauma.

Alternative techniques of LA delivery such as PDL, intraligamentary, peridental, intraseptal, and intrapulpal injections may be considered to minimize dose of LA, improve patient comfort, and improve anesthesia effect.

To avoid excess doses for the sedated patient, calculate a max dose. The dosage of LA should NOT be altered if N2O/O2 is used. When GA is employed, LA may be used to reduce the maintainence dose of anesthetic drugs.

Assessment of article: Great review of guidelines.

3/16/11 Guideline on Oral and Dental Aspects of Child Abuse and Neglect

Department of Pediatric Dentistry
Resident’s Name:Murphy Program:Lutheran Medical Center - Providence
Article title:Guideline on Oral and Dental Aspects of Child Abuse and Neglect
Journal: AAPD Guidelines
Year. Volume (number). Page #’s: 2010
Major topic: Child ABuse
Minor topic(s): Physical abuse, sexual abuse, bite marks, neglect
Main Purpose: Review the oral and dental aspects of physical and sexual abuse and dental neglect and the role of physicians and dentists in evaluating such conditions.
Overview of method of research: Review

Findings:
In all fifty states physicians and dentists are required to report suspected cases of abuse and neglect to social services or law enforcement. Physicians receive minimal training in OH and dental disease/trauma and therefore may not be able to detect dental signs of abuse and neglect.
Physical Abuse
Craniofacial, head, face, and neck injuries occur in more than half of all childhood abuse cases. Thorough intra and extra oral exam must be completed in all cases. When performing the IOE, any caries, gingivitis, or any other oral health issues should be noted and documented. Authorities believe that the oral cavity is a central focus for abuse because of it’s significance in communication and nutrition.
The lips are the most common site for inflicted oral injuries (54%), followed by the oral mucosa, teeth, gingival and tongue. Gags may cause bruising, lichenification, and scarring at the commisures.
Oral injuries from accidents are extremely common, and must be distinguished from abuse. A good history and exam should help to make the differentiation. Children that have multiple injuries, injuries at different stages of healing, or a discrepant history should arouse suspicion of abuse.

Sexual Abuse
While the OC is a frequent site of sexual abuse, visible oral injuries in kids and infections are rare. Any time oral-genital contact is suspected a referral must be made immediately to a specialized clinic equipped to conduct a comprehensive exam. Oral and periooral gonorrhea in prepubertal children is pathognomonic, but is rarely seen. Pharyngela ghonorrhea is usually asymptomatic. In terms of HPV, the mode of transmission is usually uncertain due the various ways to contract the virus.
Unexplained injury or petechia of the soft palate may be evidence of forced oral sex. Children who present with a recent history to sexual abuse may require specialized forensic testing for semen, etc resulting from the assault. Cotton swabs can be used to collect samples for analysis.

Bite Marks
Acute or healed bitemarks may indicate abuse. Bite marks should be suspected when an elliptical or ovoid pattern is found with ecchymosis, abrasions, or lacerations. Bite marks with a central ecchymoses may be cause by either positive pressure of the teeth closing, or the negative pressure caused by sucking or tongue thrust. Dog bites typically tear flesh, causing lacerations, whereas human bites cause abrasions, contusions, and lacerations by compressing tissue. An intercanine distance of >3cm indicates an adult bite. Pictures should be taken perpendicular to the bite mark. Also, any bite mark with an indentation should have a polyvinyl siloxane impression taken of it. Written observations and photographs should be taken and repeated daily for 3 days to document the bites evolution. Again, swabs should be taken to try to isolate DNA.

Dental Neglect
Dental neglect is the “willful failure of parent or guardian to seek and follow through with treatment necessary to ensure a level of oral health essential for adequate function and freedom from pain and infection.” Caries, perio disease and other oral conditions can lead to pain and infection and loss of function. These can adversely affect learning, communication, nutrition, and growth and development.
After the parent has been properly alerted by a health care professional about the nature and extent of the condition, the tx that is needed is when they may be considered negligent. The clinician must be sure the parent or guardian has been given the necessary information, and had the opportunity to ask questions regarding the condition and required tx. Clinicians should be aware of possible barriers to care, including financial aid, transportation, etc. Before neglect is considered, the clinician must be sure the parent/guardian understand the explanation of the disease, it’s implications, and the tx.

Key points/Summary:
Oral abuse and neglect are extremely serious things that we all need to be aware of and be on the look out for.

Assessment of Article:
Basic guideline put out by the AAPD. We all need to know this stuff cold.

Guideline on Management of Patients with Special Health Care Needs

Resident: Swan
Article Title: Guideline on Management of Dental Patients with Special Health Care Needs
Main Purpose: educate health care providers, parents, and ancillary organizations about the management of oral health care needs particular to individuals with SHCN.
Methods: A MEDLINE search of the current medical and dental literature related to individuals with SHCN using the terms “special needs,” “disabled,” “handicapped,” “dentistry,” and “oral health.”
Background:
The AAPD defines SHCN as “any physical, developmental, mental, sensory, behavioral, cognitive, or emotional impairment or limiting condition that requires medical management, health care intervention, and/or use of specialized services or programs…health care for individuals with special needs requires specialized knowledge, increased awareness and attention, adaptation, and accommodative measures beyond what are considered routine.”
The term SHCN applies not only to patients who suffer from limiting systemic conditions, but also to disorders which manifest only in the orofacial complex (eg amelogenesis/dentinogenesis imperfect, cleft lip/palate, oral cancer). The number of Americans with some type of disabling condition is 52 million, a number which will only increase with improvements in medical care. Today, many of these patients are seeking care from private practitioners as opposed to nursing homes or state-operated institutions. Failure to accommodate patients with SHCN could be considered discrimination and a violation of federal/state law.
These patients face many potential barriers to care, including financial (lack of insurance, high costs to families), language barriers, psychosocial issues (oral health beliefs, norms of caregiver responsibility, positive caregiver dental experience), structural (transportation, school absence policies, difficulty finding providers who accept Medicaid), priorities and attitudes (lack of importance given to oral health), increased anxiety about dental treatment.
Recommendations:
Scheduling appointments: When scheduling a patient with SHCN, the dental team should be very aware of any special considerations needed. Prior to the patient’s first visit, and after talking with the parent/caregiver on the phone to obtain the patient’s name/age/CC, name of medical care provider(s), the office should determine the need for additional appointment time or staff needed to accommodate the patient.
Dental Home: Establishment of a dental home is critical for these patients to ensure they receive appropriate preventive and routine care. If and when the patient’s needs exceed the scope of a pediatric dentist’s practice, it is important to transition smoothly to care with a dentist comfortable in the management of such a patient.
Patient Assessment: Special care should be given to ensure an accurate and comprehensive medical/dental history, with subsequent updates at each appointment. Individual treatment plans should be created based on each patient’s individual unique needs. All necessary consultations with other physicians or social workers need to be made in advance of providing treatment. As far as the actual appointment goes, much preparation can be done prior to the visit. Preferred communication methods, patient likes and dislikes can all be communicated by a parent or caregiver.
Behavior Guidance: This can be very hard with these patients. Help from parent’s/caregivers, protective stabilization, sedation, and GA are all options to consider as adjuncts.
Preventive Strategies: Because patients with SHCN are at increased risk for oral diseases, proper education of parents and caregivers is critical to ensure regular supervision of daily oral hygiene. Dentists should demonstrate oral hygiene techniques, including proper positioning of the patient. Twice daily brushing, daily flossing, dietary counseling (non-cariogenic diet, high cariogenic risk of sucrose-containing pediatric medications, carb-loaded dietary supplements), preventive measures (sealants, topical fluoride, ITR, etc.) should all be discussed. Dentists should be familiar with community based resources available to these patients.
Patients with developmental or acquired orofacial conditions: Patients with oral involvement of conditions such as OI, Ectodermal dysplasia, and Epidermolysis Bullosa often have unique financial barriers. Although oral manifestations are intrinsic to the disorder, medical health benefits often don’t provide for oral health care needs. Dentists should work with the insurance industry to recognize the medical indication and justification for such treatment.

Guideline on Use of Anesthesia Personnel in the Administration of Office-based Deep Sedation/General Anesthesia to the Pediatric Dental Patien

Meghan Sullivan Walsh March 14, 2011

Literature Review - St. Joseph/LMC Pediatric Dentistry

Guideline on Use of Anesthesia Personnel in the Administration of Office-based Deep Sedation/General Anesthesia to the Pediatric Dental Patient

Resident: Meghan Sullivan Walsh

Program: Lutheran Medical Center- Providence

Article Title: Guideline on Use of Anesthesia Personnel in the Administration of Office-based Deep Sedation/General Anesthesia to the Pediatric Dental Patient

Authors: Clinical Affairs Committee; Council on Clinical Affairs, Sedation and General Anesthesia Subcommittee

Journal: Pediatric Dentistry Reference Manual

Volume (number), Year, Page #’s; V32/NO 6 10/11, 184-186

Major Topic: Guidelines to assist the dental practitioner who elects to use anesthesia personnel for administration of GA or deep sedation in the dental office.

Overview of Method of Research: Electronic Search of current dental and medical literature using specific terms; including the 2006 guideline on pediatric sedation co-authored by the AAP and AAPD.

Findings:

Recommendations:

Personnel : A least three individuals are required for office-based deep sedation/GA. The Anesthesia care provider has the responsibility to administer or direct the administration of the drugs, monitor vitals, airway patency, cardiovascular and neurological status and adequacy of ventilation. The operating dentist and another staff member must be trained in emergency procedures.

Credentials of the anesthesia care provider must include:

1) licensed with appropriate and current state certification

2) completed a 1 or 2 year residency as approved by the ADA or AMA

3) licensed and in compliance with the laws of the state

4) if state law requires a certified nurse anesthetist or anesthesia assistant to function under the dentist’s supervision, the dentist must have completed training in deep anesthesia/GA and be licensed or permitted.

The dentists and anesthesia care provider must comply with AAP/AAPD guidelines. The concept of sedation or GA is introduced to the parents by the dentist which includes instructions and informational materials. The anesthesia care provider with explain the potential risks and obtain an informed consent. Both the dentist and staff must maintain current BLS certification and be well-versed in rescue and emergency protocols. An experienced individual in recovery care must be in attendance in the recovery facility and continually monitor the patient until it is appropriate for discharge. Emergency preparedness must be updated and practiced on a regular basis.

Facilities:

The facilities must meet the guidelines set forth by local, state and federal codes for administration of the deepest possible level of sedation. In addition the facilities will comply with applicable codes, laws and regulations pertaining to controlled drug storage, fire prevention, building construction and occupancy, accommodations for the disabled, occupational safety and health, and disposal of medical waste and hazardous waste. The treatment room will have appropriate monitors and emergency equipment. For deep sedation there must be continuous monitoring of oxygen saturation and heart rate. Temperature monitors and a pediatric defibrillator is required. Emergency equipment must be readily available including suction, oxygen and drugs.

Documentation:

Documentation will include informed consent, instructions to parents, dietary precautions, preoperative health evaluations and any prescriptions. An anesthesia record should include vital signs recorded every 5 minutes, drugs and recovery procedures.

Risk Management:

The dentist must be familiar with the ASA physical status classification. Patients must undergo a preoperative health evaluation.

Key Points: Summary:

Following guidelines during deep sedation/general anesthesia is crucial to minimize the risks of sedation to our patients.

Assessment of the Article: Succinct and thorough.

Guideline on Adolescent Oral Health Care

Meghan Sullivan Walsh March 14, 2011

Literature Review - St. Joseph/LMC Pediatric Dentistry

Guideline on Adolescent Oral Health Care

Resident: Meghan Sullivan Walsh

Program: Lutheran Medical Center- Providence

Article Title: Guideline on Adolescent Oral Health Care

Authors: Clinical Affairs Committee; Council on Clinical Affairs, Committee on the Adolescent

Journal: Pediatric Dentistry Reference Manual

Volume (number), Year, Page #’s; V32/NO 6 10/11, 119-126

Major Topic: Guidelines addressing the special needs for management of the adolescent population.

Overview of Method of Research: Electronic Search of clinical trials using specific terms, limited to the last 10 years.

Findings: Adolescence is defined as youths between the ages of 10-18. This population of patients is recognized as having special needs for the following reasons:

1) high caries rate

2) increased risk for traumatic injury and periodontal disease

3) poor nutritional habits

4) increased esthetic desire and awareness

5) complex orthodontic and restorative care

6) dental phobia

7) potential use of tobacco, drugs and alcohol

8) pregnancy

9) eating disorders

10) social and psychological needs

CARIES:

Caries rate remains highest during adolescence due to immature permanent tooth enamel, an increase in susceptible tooth surfaces, poor diet, avoidance of care, low priority for oral hygiene and social factors.

Management: Primary prevention

Fluoride dependent on risk assessment.

1) Brush 2x daily

2) Topical fluoride based on CRA

3) Home RX based on CRA

4) Systemic fluoride or supplements up to age 16

Oral Hygiene:

Adolescence can prove to be a time of increased caries risk due to the increased intake of cariogenic substance and lack of good oral hygiene:

1) Adolescents should be educated and motivated to maintain good hygiene

2) Professional prophylaxis dependent on CRA

Diet: Adolescents are at risk for consuming high quantities on refined carbohydrates and acid containing beverages. Recommendations include:

1) Diet analysis and management

2) Sealants based on risk

Secondary Prevention

Professional Care:

1) Timing is dependent on risk indicators and needs

2) Initial and periodic radiographs accepted by the guidelines

Restorative:

Preservation of tooth structure is desirable as well as esthetics and the patient’s needs. Molars with extensive needs may require full coverage restorations. Restorative needs are recommended on an individual basis and a referral should be made if the work is beyond the dentist’s scope of practice

PERIODONTAL DISEASE:

Irreversible tissue damage from periodontal disease may begin in late adolescence. In addition adolescents have a higher prevalence on gingivitis than children and adults. The rise of sex hormones is attributed to this prevalence.

Acute conditions:

Conditions such as ANUG and periodontitis is common and must be addressed immediately. Therapy is dependent on the individuals needs and appropriate referrals should be made if necessary.

Chronic conditions:

Frequently seen conditions in this population include gingivitis, puberty gingivitis, hyperplastic gingivitis, hyperplastic gingivitis related to ortho, gingival recession, drug-related gingivitis, pregnancy gingivitis, localized juvenile periodontitis and periodontitis.

Recommendations for this population include:

1) Education

2) Age appropriate oral hygiene program

3) Regular professional intervention including perio charting and radiographs

4) Evaluation for procedure to facilitate ortho ie frenectomy, tooth ext, fiberotomy...

OCCLUSAL CONSIDERATION

Malocclusion:

Treatment based on professional diagnosis may include malposition of teeth, malrelationship of teeth to jaws, tooth/jaw size discrepancy or disfigurement that prevents function, esthetics, etc. Appropriate referrals should be made if the treatment is out of the dentists scope of practice.

Third molars:

Third molars can present acute and chronic conditions that merit evaluation for removal. Removing third molars by the third decade is recommended because of high probability of disease or pathology and risks associated with removal at a later time. Continuous evaluations should be made and appropriate referrals given when necessary.

TMJ problems:

Evaluation and examination of this joint should be a part of every recall. TMD appears more prevalent during adolescence.

Congenitally missing teeth:

Evaluation and management should include both immediate and long term treatment based on age, esthetics, growth potential, perio and oral surgical needs.

Ectopic eruption:

Dentist must be proactive in the diagnosis and management of ectopic eruption. Prevention may include extraction of deciduous teeth, surgery, endo, perio, etc.

TRAUMA:

Dentists should introduce a comprehensive trauma prevention program including the patient’s sport or activity, level and frequency of activity. Recommendation and fabrication of a sport specific mouth guard should be initiated.

Additional considerations:

Discolored or stained teeth:

Judicious use of bleaching may be considered based on a comprehensive diagnosis. The least invasive and most effective treatment should be rendered and monitored.

Tobacco:

Education and appropriate counseling services should be provided. Associated pathology should be monitored and referred appropriately.

Positive youth development:

Physchological and social needs are a crucial part of this age group. A strong interpersonal relationship between the adolescent and the pediatric dentist can be influential in improving the patient’s oral health and transitioning to adult care. Recommendations are for the dentist to get involved in community organizations and schools.

Psychological:

Dentists must be aware of the behavioral considerations including anxiety, phobia and intellectual dysfunction. Consent, confidentiality and compliance should be addressed and a complete oral health care program is required.

Transitioning to adult care:

Educating the patient and parent on the value of transitioning to a dentist who is knowledgeable in adult oral health is important. This transition may be difficult for persons with special health care needs. Should there be no practitioner who is comfortable treating SHCN patients, the pediatric dentist can remain their dental home.

Key Points: Summary:

Adolescents have a myriad of distinctive needs. We should be aware of the social as well as health issues which affect this population and treat appropriately.

Assessment of the Article: Thorough review. As if being a teenager isn’t tough enough...

Guideline on Infant Oral Health Care

Resident: Cho
Journal: AAPD Clinical Guidelines 2010-2011

Main Purpose: To provide guidelines for infant oral health care in order to enhance the opportunity for a lifetime free from preventable oral disease.

Methods:
Systematic literature search of the MEDLINE/Pubmed electronic database using the following parameters: infant oral health , infant oral health care, and early childhood caries.

Key points/Summary:
- More than 40% of children have caries by the time they reach kindergarten.
- ECC affects infants from low SES, high sugar diet, mothers who have low education: 32 times more than the general population.
- Vertical colonization of MS from mother to infant is well documented. Also, recent reports have indicated horizontal transmission (transmission between members of a group, such as siblings of similar age or children in a daycare center).

Recommendations by AAPD:
1. All primary health care professionals who serve mothers and infants provide parent/caregiver education on the etiology and prevention of ECC.
2. The curriculum of all medical, nursing, and allied health professional programs should include information about ECC (source is an infectious and transmissible bacteria), methods of oral health risk assessment, anticipatory guidance, and early intervention.
3. Every infant receive oral health risk assessment by the age of 6 months:
- assessing patient’s risk of developing oral disease using caries risk assessment
- providing education on infant oral health
- evaluating and optimizing fluoride exposure
4. Parents or caregivers establish a dental home for infants by 12 months of age.
5. Health care professionals and others involved in children’s oral health should support the identification of a dental home for all infants at age of 12 months.
6. Legislators, policy makers, and third party payors be educated about the benefits of early interventions in order to support efforts that improve access to oral health care for infants and children.

Assessment of Article: Good overview of infant oral care.

Guideline on Caries risk Assessment and Management for Infants, Children, and Adolescents

Resident: Roberts

Date: 3/16/11

Article: Guideline on Caries risk Assessment and Management for Infants, Children, and Adolescents

Journal: Oral Health Policies

Volume: 32 pages: 101 - 107

Year: 2010

Purpose:

The AAPD recognizes and uses the Caries-risk Assessment Tool(CAT) for diagnosis and management of caries in Infants, children and adolescents. The purpose of this paper was intended to educate the clinician in decision making regarding diagnostic, fluoride, dietary and restorative protocols using the most updated and approved material by the AAPD.

Methods

This paper is an update to the guideline approved by the AAPD “ policy on Use of a Caries-risk Assessment Tool for Infants, children, and Adolescents, revised in 2006.

A search within the last ten years was performed using criteria, “caries risk assessment”, “caries clinical protocols” which yeilded 1909 ariticles of which 75 were used in formulation of the article.

Background

Caries risk assessment models currently involve a combination of factors including diet,fluoride exposure, a susceptible host and microflora that interplay with a variety of social cultural and behavioral factors. Caries risk assessment is the determination of of the likelihood of caries or the likelihood of change in caries status within a host. Although all factors can play a part in the likelihood of a patient to be susceptible to caries the patients past caries experience is the best predictor of future development of the disease.

Factors to identify High/moderate risk patients include:

High risk category

Primary caregiver has active cavities

Primary caregiver has low SES

Child has more than 3 sugar containing snacks or beverages between meals a day

Child is put to bed with a bottle containing natural or added sugar

Child has white spot lesions(more than 1)

Child has visible cavities or fillings

Child has elevated mutans streptocoocci levels

Patient has more than one interproximal lesion

Patient has low salivary flow

Does not use fluoridated water or toothpaste

Moderate risk

Child has one white spot lesion

Child has 1 or 2 sugary snacks or beverages between meals

Child has special health care needs

Child is a recent immigrant(3x higher to have ECC)

Child has visible plaque on teeth

Patient is wearing an intraoral appliance

Patient has defective restorations

Uses fluoridated toothpaste but not water

Conclusion

Patients with moderate/high risk status should have xrays more frequently than low risk, their oral hygiene regime may include a high dose fluoride dentrifice, a professional topical application of fluoride on a more frequent basis(3 months) and will need counseling to instruct the parents on matters of concern such as diet( sugar substitutes such as xylitol, sugary snacks and beverages), fluoride exposure (via water, toothpaste, and in office tx), regular dental visits, and preventive measures such as sealants.

Assessment

The article was good however the diagrams did not include all the risk categories from the AAPD handbook. This article shies away from being too detailed, and would be a great article to refer to friends and colleagues within the medical health profession.

Oral manifestations of aplastic anemia in children

Resident: Roberts

Date: 3/8/2011

Article title: Oral manifestations of aplastic anemia in children

Authors: Supulveda Ester

Journal: Jada

Volume 137 pages: 474 - 478

Year: 2006

Aplastic Anemia is a rare blood dyscrasia in which peripheral blood pancytopenia( defects in host defense) results from reduced or absent blood cell production in the bone marrow, and normal hematopoietic replaced by fatty marrow. The estimated incidence of AA is two new cases per 1 million person per year. The disease is rare in children and the peak age of occurrence is between and 5 years. The disorder can be inherited, idiopathic or acquired, the causes include radiation therapy, intake of drugs and chemicals, viral infections, thymoma, pregnancy and paroxysmal nocturnal hemoglobinuria. Severe AA is defined by two of three criteria: 1. low neutrophil count (500 cells/cubic mm) 2. low platelet count (20,000 cells/cubic mm) 3. low reticulocyte count (200 cells/ cubic mm). Therapy includes Bone marrow transplantation and immunosuppresive therapy in circumstances where identical siblings is present and immunosuppressive therapy for all other children.

Purpose: to describe oral lesions in children with AA.

Methods: Retrospective review of patients seen at a hospital in Concepcion, Chile between the years March 1996 and May 2001.

Results: Twelve children were diagnosed with AA. Their age range was 3 to 12 years (median age range was 7). Nine subjects were receiving immunosuppresive therapy, and three only supportive care. The most common oral manifestation of the disease was hemorrhage, which developed most often in patients with low platelet counts. This was followed by candidiasis and viral infection.

Conclusion: Neutropenia, caused by the disorder itself and its treatment, leads to an increased susceptibility to infection and thrombocytopenia which leads to bruising and mucosal bleeding: both of theses complications correspond to sepsis (including oral manifestations - often the first sign) and hemorrhage, the main causes of death in these patients.

Assessment: This study was obviously limited by the number of sample size. Further investigation is needed.