"pediatric oral health "
TRANSCRIPT
Pediatric Oral HealthPediatric Oral Health
Bob Selvester, MDLCDR MC USN
Family PhysicianInterservice Physician
Assistant Program
Prevalence of Dental Caries
• 5 times more common than asthma
• 7 times more common than hay fever
Caries Rate
• 18% aged 2 to 4 years
• 52% aged 6 to 8 years
• 67% aged 12 to 17 years
Learning ObjectivesLearning Objectives
1) State the key components of a primary care oral health history and physical examination.
2) State the recommended intervals for examination by a Dental Health professional.
3) Recognize indications for referral
AAPA/PAEA/NCCPA/ARC-PAAAPA/PAEA/NCCPA/ARC-PA
• Do not address expectations for oral health except to say there must be training in all body systems
AAFPAAFP
• Dietary fluoride supplements should be considered for children from ages 6 months through 16 years when drinking water levels are suboptimal.
• The AAFP recognizes avoidance of tobacco products by children and adolescents is desirable.– The effectiveness of physician advice and
counseling in this area is uncertain.
USPSTF RecommendationsUSPSTF Recommendations
• Evidence is insufficient to recommend for or against routine risk assessment of preschool children by primary care clinicians for the prevention of dental disease (Rating I)
• Primary care clinicians prescribe oral flouride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source is deficient in flouride. (Rating B)
AAPAAP
• Prior to 2000, initial exam by Dentist was recommended at age of 3.
The American Academy of Pediatrics
Oral Health Initiative
The American Academy of Pediatrics
Oral Health Initiative
Wendy Nelson
Manager Oral Health Initiative
January 25, 2008
The American Academy of Pediatrics
Oral Health Initiative
The American Academy of Pediatrics
Oral Health Initiative
www.aap.org/oralhealth
Oral Health Risk Assessment: Training for Pediatricians and Other Child Health
Professionals
Developed by the American Academy of Pediatrics Oral Health Initiative
Supported in part by the Maternal and Child Health Bureau,
Health Resources and Services Administration Department of Health and Human Services
U93MC00184
View the training online at www.aap.org/oralhealth/cme.
Background
Factors Necessary for Caries
Brief Pathophysiology
• Cariogenic Bacteria• Frequency of exposure • Contact time• Acidity
Oral Flora: How Does Infection Occur?
• Transmitted mainly from mother or primary caregiver to infant
• Window of infectivity is first 2 years of life
• Earlier child colonized, the higher the risk of caries
Substrate: You Are What You Eat
• Caries is promoted by carbohydrates, which break down to acid.
• Acid causes demineralization of enamel.
• Frequent snacking promotes acid attack.
• Foods with complex carbohydrates (breads, cereals, pastas) are major sources of “hidden” sugars.
• High sugar content in sodas is a source of these substrates.
Fluoride’s Influence on Oral Flora
• Promotes remineralization of enamel, and may arrest or reverse early caries
• Decreases enamel solubility
• Inhibits the growth of cariogenic organisms, thus decreasing acid production
• Concentrated in dental plaque
• Primarily topical even when given systemically
Not Just What You Eat, But How Often
• Acids produced by bacteria after sugar intake persist for 20 to 40 minutes.
• Frequency of sugar ingestion is more important than quantity.
Substrate: Environmental Influences
• Saliva inhibits bacterial growth.
• Unremoved plaque promotes the caries process.
Red disclosing tablet reveals plaque
AAP Recommendations for an Oral Health Risk Assessment
• Assess mothers’/caregiver’s oral health.
• Assess oral health risk of infants and children.
• Recognize signs and symptoms of caries.
• Assess child’s exposure to fluoride.
• Make timely referral to a dental home.
• Provide anticipatory guidance including oral hygiene instructions (brush/floss).
History
High-Risk Groups for Caries
• Children with special health care needs
• Children from low socioeconomic and ethnocultural groups
• Children with suboptimal exposure to topical or systemic fluoride
• Children with poor dietary and feeding habits
• Children whose caregivers and/or siblings have caries
Fluoride Exposure
• Determine fluoride exposure: systemic versus topical
• Fluoridated water– 58% of total population
– Optimal level is 0.7 to1.2 ppm
– Significant state variability
– CDC fluoridation map
Examination
Positioning Child for Oral Examination
• Position the child in the caregiver’s lap facing the caregiver.
• Sit with knees touching the knees of caregiver.
• Lower the child’s head onto your lap.
• Lift the lip to inspect the teeth
and soft tissue.
Primary Teeth Eruption
Check for Normal Healthy Teeth
Check for Early Signs of Decay: White Spots
Check for Later Signs of Decay: Brown Spots
Check for Advanced/Severe Decay
Assessment
AAPD Caries Risk Assessment Tool (CAT)
Chart based on the AAPD Caries-Risk Assessment Tool. For more information on using the tool, refer to http://www.aapd.org/foundation/pdfs/cat.pdf.
Low Risk Moderate Risk High Risk
Clinical Conditions
- No carious teeth in past 24 months- No enamel demineralization (enamel caries “white- spot lesions”)- No visible plaque; no gingivitis
- Carious teeth in the past 24 months- 1 area of enamel demineralization (enamel caries “white-spot lesions”)- Gingivitis
- Carious teeth in the past 12 months- More than 1 area of enamel demineralization (enamel caries “white- spot lesions”)- Visible plaque on anterior (front) teeth- Radiographic enamel caries- High titers of mutans streptococci- Wearing dental or orthodontic appliances- Enamel hypoplasia
EnvironmentalCharacteristics
- Optimal systemic and topical fluoride exposure- Consumption of simple sugar or foods strongly associated with caries initiation primarily at mealtimes- Regular use of dental care in the established dental home
- Suboptimal systemic fluoride exposure with optimal topical exposure- Occasional between meal exposures to simple sugar or foods strongly associated with caries- Mid-level caregiver socioeconomic status (ie, eligible for school lunch program or SCHIP)- Irregular use of dental services
- Suboptimal topical fluoride exposure- Frequent (ie, 3 or more) between-meal exposures to simple sugars or foods associated strongly with caries- Low-level caregiver socioeconomic status (ie, eligible for Medicaid)- No usual source of dental care- Active caries present in the mother
General Health Conditions
- Children with special health care needs- Conditions impairing saliva composition/flow
Cari
es R
isk I
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Referral
Initial Screening by Initial Screening by Child Dental ProfessionalChild Dental Professional
• By 12 months of age or 6 months after eruption of first tooth (whichever is sooner)—even natal teeth . . . – All children at “High Risk”—as early as
6 months of age. (earlier)– Any child with visible caries, plaque, or
decay (right away)
Referral: Establishment of Dental Home
What is a dental home?
When to refer?
• Refer high-risk children by 6 months.
• Refer all children by 1 year.
Anticipatory Guidance
Anticipatory Guidance
• Minimize risk of infection.
• Optimize oral hygiene.
• Reduce dietary sugars.
• Remove existing dental
decay.
• Administer fluorides
judiciously.
Xylitol for Mothers/Children
• Helps reduce the development of dental caries
• A “sugar” that bacteria can’t use easily
• Resists fermentation by mouth bacteria
• Reduces plaque formation
• Increases salivary flow to aid in the repair of damaged tooth enamel
Xylitol gum or mints used 4 times a day may prevent transmission of cariogenic bacteria to infants.
Substrate: Contributing Dietary and Feeding Habits
• Frequent consumption of carbohydrates, especially sippy cups/bottles with fruit juice, soft drinks, powdered sweetened drinks, formula, or milk
• Sticky foods like raisins/fruit leather (roll-ups), and hard candies
• Bottles at bedtime or nap time not containing water
• Dipping pacifier in sugary substances
Optimizing Oral Hygiene: Flossing
When to Use Floss
• Once a day (preferably at night)
• Whenever any 2 teeth touch
Toothbrushing Recommendations
AgeToothbrushing
Recommendations (CDC, 2001)
< 1 year ~ Clean teeth with soft
toothbrush
1–2 years ~ Parent performs brushing
2–6 years ~ Pea-sized amount of fluoride- containing toothpaste 2x/day
~ Parent performs or supervises
> 6 years ~ Brush with fluoridated toothpaste 2x/day
Toothpaste and Children
• Children ingest substantial amounts of toothpaste because of immature swallowing reflex.
• Early use of fluoride toothpaste may be associated with increased risk of fluorosis.
• Once permanent teeth have mineralized (around 6-8
years of age), dental fluorosis is no longer a concern.
Toothpaste
A small pea-sized amount of toothpaste weighs 0.4 mg to 0.6 mg fluoride, which is equal to the daily recommended intake for children younger
than 2 years.
Example of Fluorosis
Mild Fluorosis Severe Fluorosis
Recommended Fluoride Supplement Schedule
None0.50 mg/day
1.0 mg/day6 yrs–16 yrs
None0.25 mg/day
0.50 mg/day
3 yrs–6 yrs
NoneNone0.25 mg/day
6 mo–3 yrs
NoneNoneNone0–6 months
>0.6 ppm0.3–0.6 ppm
<0.3 ppmAge
Fluoride Concentration in Community Drinking Water
MMWR: Recommendations for Using Fluoride to Prevent and Control Dental Caries in the US: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm.
CME Credit
Take this training online to earnContinuing Medical Education
credit!
http://www.aap.org/oralhealth/cme
Questions about this training?E-mail [email protected].
Photo Credits
Special thanks to the following individuals andorganizations for contributing to this training:
AAP Breastfeeding InitiativesAmerican Academy of Pediatric DentistryAmerican Dental AssociationANZ PhotographySuzanne Boulter, MDGeorge Brenneman, MDContent VisionaryMelinda Clark, MDJoanna Douglass, BDS, DDS
Rani Gereige, MDDonald Greiner, DDS, MScIndian Health ServiceMartha Ann Keels, DDSSunnah KimCynthia Neal, DDSRama Oskouian, DMDP&G Dental ResourceNetMichael San FilippoGregory Whelan, DDS
Credits
Special thanks to the following individuals for contributing to the development of this training:
Primary AuthorsSuzanne Boulter, MD, FAAPPaula Duncan, MD, FAAPKevin Hale, DDSMartha Ann Keels, DDS, PhDDavid Krol, MD, MPH, FAAPWendy Mouradian, MD, MS, FAAPWendy Nelson, ACCE
Additional ContributorsBetty Crase, IBCLC, RLCMartin J Davis, DDSAdriana Segura Donly, DDS, MSRocio B Quinonez, DMD, MS, MPHKathleen Marinelli, MD, IBCLC, FAAP