Elizabeth Shick, DDS, MPHAssistant Professor, University of Colorado School of Dental

Medicine

Oral Health Care and Adolescents: Latest Research and Clinical Implications

Colorado Association of School-Based Health Care

May 2, 2013

I have no relevant financial relationships with any commercial

interests.(But I will shamelessly pull pictures from Google

Images)

Goals and Objectives Understand how oral health fits into the School-

Based Health Care system

Review management strategies of dental caries (Dentistry 101)

Review urgent oral health problems and when to make a dental referral

Discuss preventive strategies for adolescents

Discuss other adolescent specific oral health topics

National Center for Health Promotion Data, May 2012

13.3% of 12-19 year olds had active caries Adolescents spend ~1260 hours/year in school School-based health clinics present a great

opportunity to reach adolescents to improve their oral health

The Problem

Coordinated School Health Programs

The 8 components of a Coordinated School Health Program, CDC

• Promoted by public health and government health agencies such as the Centers for Disease Control (CDC), Colorado Department of Education (CDE), and Association of State and Territorial Dental Directors (ASTDD)

• Oral health fits into each component and is important for good general health

#8

Resource: ASTDD School and Adolescent Oral Health Committee

How to integrate oral health

#1) Health Education:Oral health counseling• Prevention (brushing and flossing at home)• Diet/nutrition counseling• Caries diagnosis • Fluoride• Diet/nutrition• Alcohol/drug counseling (oral cancer, meth mouth)• Smoking and smokeless tobacco counseling• Pregnancy and perinatal oral health counseling

Resource: ASTDD School and Adolescent Oral Health Committee Presentation by Linda L. Koskela RDH, MPH, Chair SAOH

How to integrate oral health

#2) Health Services:• All children should have a dental

home• Make dental referrals (know your

community)• Provide preventive services on

site:• Fluoride varnish application or

fluoride rinse program• Perform oral health screenings• Apply sealants

http://www.google.com/url?sa=i&rct=j&q=colorado+smilemakers+mobile+dental+clinic&source=images&cd=&cad=rja&docid=s5oRRmMBVl-WgM&tbnid=xe7Zjf9A6TgLGM:&ved=0CAUQjRw&url=http://www.ucdenver.edu/academics/colleges/dentalmedicine/CommunityService/Pages/CommunityService.aspx&ei=yFtwUZ2KIMnrygHlwoCAAw&bvm=bv.45373924,d.aWc&psig=AFQjCNE0KudFlr-4XVR65BPVop9TmgcpZg&ust=1366404418782183

How to integrate oral health

#3) Nutrition Services:• Nutrition related to dental caries• Recommend balanced diet low in sugar• Recommend limiting consumption of sweetened

beverages• Recommend limit snacking and healthy snacking• Bulimia and anorexia• Obesity• Diabetes• School vending machines

How to integrate oral health

#4) Healthy School Environment:

• School policy on vending machines• Health choices on cafeteria menu, salad bar,

etc• Smoking policy• Injury prevention• Security to prevent fights leading to trauma

How to integrate oral health

#5) Family and Community Involvement:

• Community health fairs• Invite dental providers to speak to parents• Invite dental providers to perform oral

screenings• Hold educational seminars for parents about

prevention at home• Make dental referrals

How to integrate oral health

#6) Counseling, Psychological and Social Services:

• Children with dental problems miss more days of school

• Dental caries may lead to poor school performance

• Dental caries may lead to low self-esteem

• Parents may need information about accessing public insurance programs (Ie: Medicaid, CHP+)

How to integrate oral health

#7) Health Promotions for Staff:

• Staff development programs promoting healthy lifestyles

• Programs that offer incentives to staff (Ie: weight loss challenges, walking mileage challenges)

• Exercise promotion (Ie: on site facilities at Universities)

• Smoking cessation programs• Offer mental health services• Staff oral health status??

How to integrate oral health

#8) Physical Education (PE):• Promote keeping PE and recess in schools• Develop afterschool programs promoting PE • Promote community sports (soccer, baseball

leagues)• Host a 5K run/walk event to benefit the school• Sports mouth guards programs• Be familiar with how to treat dental trauma• Have resources available for dental referral

when needed in urgent situations

School Performance Research shows that students with oral health

problems have lower school performance and more missed school days

Jackson SL, Vann WF Jr, Kotch JB, Pahel BT, Lee JY. Impact of poor oral health on children's school attendance and performance.Am J Public Health. 2011 Oct;101(10):1900-6.

Seirawan H, Faust S, Mulligan R. The impact of oral health on the academic performance of disadvantaged children. Am J Public Health. 2012 Sep;102(9):1729-34.

Dental Caries

• Review of dental anatomy

• Progression of a cavity

Dental EmergenciesTwo basic types:

Trauma

Infection

In the news…

Deamonte Driver12 years old

Prince Georges County, Maryland

Died February 27, 2007

Cause of death: complications from dental infection

Does anyone recognize him?

Abscess noted near gumline

Facial swelling

Oral evaluationCavities or past dental treatment

Facial Swelling

• Facial swelling accompanied by pain, limited opening and deviation on opening.

• Evaluate if swelling is into orbit or will obstruct airway.

Toothache AlgorithmStudent presents with toothache

No facial swelling

Presence of facial swelling

Refer to dentist for treatment

If orbit and airway

unaffected, Rx antibiotic, root

canal therapy or extraction of

tooth

If orbit or airway are affected, Rx

antibiotic, consider IV

antibiotic and eval if I&D is

needed, extraction of

tooth

Not urgent

Urgent

Begin antibiotic therapy

Tylenol/Ibuprofen for pain

Seek dental care immediately• Root canal therapy or extraction indicated• May require incision and drainage• Oral Maxillo-Facial Surgeon may be needed

If no dentist available, consider admitting to hospital and maintaining on antibiotic until dental care is available, especially if swelling invades orbit or airway

Facial Swelling

Antibioticso Oral:

• Amoxicillin 20-40mg/kg/day in divided doses every 8 hours

• If penicillin allergic: Clindamycin 8-20mg/kg/day in 3-4 divided doseso IV

• Unasyn 100-400 mg/kg/day in divided doses every 6 hours

• Clindamycin 20-40 mg/kg/day in 3-4 divided doses

Facial Swelling

Root canal therapy:o Provides drainage of infection via canal space and crown

of tootho Pulp is removed, canals are cleaned and disinfected and

then filled with biocompatible material such as gutta percha or MTA (mineral trioxide aggregate)

o Tooth usually requires a crown placed after that within 1 month of treatment ideal

o >95% success rates for permanent teeth Extraction:

o Remove the sources of infection and provide drainage through the socket site

o 100% successful

Treatment

Dental Trauma

Most common site maxillary incisors (upper front teeth)

Most common accidents:o Fallso Bike/Car accidentso Sports related injurieso Violence (at school)o Abuse

Dental Trauma

Medical Clearance If severe refer student for physical exam:

o Neurological assessmento Loss of consciousnesso Nausea/Vomitingo Headacheo Lethargyo Seizureso Vision problemso Tetanus exposure

Dental Trauma Terminology• Fracture – partial loss of tooth surface due to trauma

- uncomplicated (no pulp exposure)- complicated (with pulp exposure)- root fracture

• Subluxation – mobility of tooth, position unchanged

• Luxation – change of tooth position- intrusion or extrusion- lingual or facial- lateral

• Avulsion – complete loss of entire tooth from socket

• Soft tissue laceration - injury resulting in cut or break in skin or soft tissue

Uncomplicated Fracture

• Uncomplicated- Enamel, dentin only- Does not extend into pulp tissue- Usually not associated with pain- If painful, usually just cold/hot

sensitivity- May wait to see dentist pending

patient’s pain level and ability to eat- Treatment: Smooth edges or composite

build-up

Complicated Fracture• Complicated

- Nerve is exposed- Associated with higher pain- Require more invasive treatment (root canal therapy)

- Refer to dentist for treatment immediately if patient has intolerable pain or next day if mild/no pain (24-48 hours OK of patient can tolerate)- Treatment: may involve root canal therapy, restoration with filling or crown

There may be a root fracture post trauma with no evident signs

Dentists take 3 x-rays at 3 different angles to diagnose this

Poor prognosis for tooth Treatment: varies from monitoring to

extracting the tooth and root tip Even patient with mild dental

trauma should follow up with dentist next day to rule out root fracture

Root Fracture

Subluxation• Mobility of tooth post trauma (also

called concussion)

• May refer to dentist next day if patient is comfortable and able to eat for x-ray and evaluation

• Instruct patient to avoid eating or placing pressure on tooth

Luxation - Intrusion• Intrusion injuries result in tooth being

pushed upwards, may infringe on developing permanent tooth above

• Instruct patient to avoid eating or placing pressure on tooth

• Refer to dentist, may wait next day pending patient’s pain and ability to eat

• Extrusion results in tooth being pulled downward out of socket post trauma

• Gently push back into place if possible, the sooner the better

• Instruct patient to avoid eating or placing pressure on tooth

• Refer to a dentist immediately if patient cannot bite teeth together normally, tooth is very loose or high pain level

• If not corrected and bone re-ossifies can be very difficult to correct later

Luxation - Extrusion

• Facial, lingual, mesial, distal luxations may be gently pushed back into place if possible

• Evaluate if position of tooth interferes with patient’s teeth biting together

• Instruct patient to avoid eating or placing pressure on tooth

• Refer to dentist immediately if patient cannot bite teeth together normally, tooth is very loose or high pain level

Lateral Luxation

• Results in complete loss of tooth• Primary teeth are not replanted• Permanent teeth should be replanted into socket

site ASAP• Prognosis of tooth depends on time outside the

mouth• The faster the tooth is re-implanted, the better

prognosis it has

Avulsion

- Replant on the spot if possible

- Transport tooth in Save-A-Tooth, milk or saliva

- DO NOT store in water - Handle tooth by crown, not

root- Seek dental care

immediately

Avulsion

Post Op Instructions Avoid eating with front teeth Keep area very clean Tylenol for pain Evaluate tetanus status if trauma involved dirt

exposed area Antibiotic indicated for avulsion 2 week follow up

Laceration Injuries Dentist comfortable suturing intra-orally Prefer MD to suture extra-orally or any esthetic

area, including vermillion of lip Evaluate laceration as through and through or not Keep in mind if patient chipped tooth but has not

found piece of tooth, may be embedded in laceration site (can be evaluated by x-ray)

Prevention Home care and Fluoride

• Drink water from a fluoridated source (inquire about bottled water)

• Flossing once/day, brushing twice/day with fluoridated toothpaste at home

• Act or other fluoride mouth rinse if high risk• Special precautions with orthodontic appliances• Involve parents if needed, supervision may be

required

Professional care• Ask about dental home• Make dental referrals• Get familiar with community resources for children’s

oral health

Prevention Diet

• Balanced diet low in sugar and fermentable carbohydrates

• Limit sweetened beverages to one/day• Encourage healthy snacking• Limit smacking frequency to twice/day between

meals• Encourage more water consumption• Avoid vending machines at school• Discuss how to navigate the cafeteria in a healthy

way• Limit sports drinks like Gatorade, water is preferred

Sports Mouth Guards The American Academy of Pediatric Dentistry

(AAPD), the American Academy of Orthodontics (AAO) and the American Academy of Pediatrics (AAP) all recommend children wear sports mouth guards when participating in sports

Over the counter methods are ill-fitting and will not adequately protect teeth

Recommend custom made mouth guards from the dentist

Duddy FA, Weissman J, Lee RA Sr, Paranjpe A, Johnson JD, Cohenca N. nfluence of different types of mouthguards on strength and performance of collegiate athletes: a controlled-randomized trial. Dent Traumatol. 2012 Aug;28(4):263-7.

Bruxism/Grinding Normal part of life Considered stress related Severity depends on amount of

tooth structure that is worn away from this habit

Usually not treated in children Recommend night guards when all

permanent teeth are in Over the counter night guards are

ill fitting, not recommended Dentist can fabricate custom

made night guard

Orthodontic Appliances Most common time of orthodontic treatment is

during adolescence Approximately 20% of population have

orthodontic needs Students may present with pain from broken wire,

overextended wire, wire that has come out of bracket or de-bonded band or bracket

Placing wax over site is a quick fix Patient should see orthodontist treating them for

help

Oral Piercings Increased risk of:

• Infection• Chipped teeth•Gingival recession

Plessas A, Pepelassi E. Dental and periodontal complications of lip and tongue piercing: prevalence and influencing factors. Aust Dent J. 2012 Mar;57(1):71-8.

Drew Barrymore

Substance Use Smokeless tobacco (dip, snuff, chew)

• Users are at increased risk of oral cancer but lower risk than smokers

Meth mouth (public ad campaigns) • Patients present with poor oral hygiene,

rampant caries, dry mouth

Ravenel MC, Salinas CF, Marlow NM, Slate EH, Evans ZP, Miller PM. Methamphetamine abuse and oral health: a pilot study of "meth mouth". Quintessence Int. 2012 Mar;43(3):229-37.

Smoking Cessation Known high risk of oral cancer National ad campaigns Important to provide smoking cessation

counseling in the school-based health care system

Have the tools to help adolescents

Diemert LM, Bondy SJ, Brown KS, Manske S. Young adult smoking cessation: predictors of quit attempts and abstinence. Am J Public Health. 2013 Mar;103(3):449-53.

National Youth Tobacco Survey*

Question % Yes % NoHave you ever tried smoking cigarettes? 29% 69%Have you ever tried smoking cigars, cigarillos, little cigars?

19% 77%

Have you ever tried chewing tobacco? 11% 87%Have you ever tried smoking with a pipe? 7.5% 91%Have you ever smoked with a hookah or water pipe?

7.3% 93%

During the past year did any doctor, dentist or nurse ask you about tobacco use?

29% 61%

During the past year did any doctor, dentist or nurse advise you not to use tobacco?

28% 61%

During the past year did your parents talk with you about not using?

39% 58%*Data for 6th-10th graders

• 31% reported it would be “Very easy” to get cigarettes

• 64% reported they thought tobacco companies are trying to get underage people to smoke

• 6.5% reported that they tried to quit on their own or cold turkey in the past year

• 32% reported that someone they live with smokes cigarettes

National Youth Tobacco Survey*

Summary School-based Health Clinics can offer an array of

oral health services that will benefit adolescents

School-based Health Clinic staff can be knowledgeable about various oral health problems afflicting adolescents

Having the proper tools and community resources to implement an oral health component will benefit the School-based Health Clinic and the adolescents it serves

Oral Health and Pregnancy

California Dental AssociationPerinatal Oral Health Practice GuidelinesAvailable at: www.cdafoundation.org/learn/perinatal_oral_health

New York State Department of HealthOral Health Care During Pregnancy and Early Childhood Practice GuidelinesAvailable at:www.health.state.ny.us/publications/0824.pdf

(My own picture of Vail)