Transcript Colorado Association For School

Oral Health Care and Adolescents:
Latest Research and Clinical Implications
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Elizabeth Shick, DDS, MPH
Assistant Professor, University of Colorado School of Dental Medicine
I have no relevant financial relationships
with any commercial interests.
(But I will shamelessly pull pictures from Google Images)
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Understand how oral health fits into the School-Based
Health Care system
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Review management strategies of dental caries (Dentistry
101)
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Review urgent oral health problems and when to make a
dental referral
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Discuss preventive strategies for adolescents
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Discuss other adolescent specific oral health topics
National Center for Health Promotion Data, May 2012
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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
#8
• 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
The 8 components of a Coordinated School Health Program, CDC
Resource: ASTDD School and Adolescent Oral Health Committee
#1) Health Education:
Oral health counseling
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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
#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
#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
#4) Healthy School Environment:
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School policy on vending machines
Health choices on cafeteria menu, salad bar, etc
Smoking policy
Injury prevention
Security to prevent fights leading to trauma
#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
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#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 selfesteem
• Parents may need information about
accessing public insurance programs
(Ie: Medicaid, CHP+)
#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??
#8) Physical Education (PE):
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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
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Research shows that students with oral health problems
have lower school performance and more missed school
days
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.
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.
• Review of dental anatomy
• Progression of a cavity
Two basic types:
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Trauma
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Infection
Deamonte Driver
12 years old
Does anyone
recognize him?
Died February 27, 2007
Prince Georges County, Maryland
Cause of death: complications from dental
infection
Cavities or past
dental treatment
Facial swelling
Abscess noted near gumline
•Facial swelling accompanied by pain, limited opening and deviation on
opening.
•Evaluate if swelling is into orbit or will obstruct airway.
Student presents with toothache
No facial swelling
Presence of facial
swelling
Not urgent
Urgent
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
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Begin antibiotic therapy
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Tylenol/Ibuprofen for pain
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Seek dental care immediately
• Root canal therapy or extraction indicated
• May require incision and drainage
• Oral Maxillo-Facial Surgeon may be needed
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If no dentist available, consider admitting to hospital and
maintaining on antibiotic until dental care is available,
especially if swelling invades orbit or airway
 Antibiotics
o Oral:
• Amoxicillin 20-40mg/kg/day in divided doses every 8
hours
• If penicillin allergic:
Clindamycin 8-20mg/kg/day in 3-4 divided doses
o IV
• Unasyn 100-400 mg/kg/day in divided doses every
6 hours
• Clindamycin 20-40 mg/kg/day in 3-4 divided doses
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Root canal therapy:
o Provides drainage of infection via canal space and crown of tooth
o 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
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Extraction:
o Remove the sources of infection and provide drainage through the
socket site
o 100% successful
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Most common site maxillary incisors (upper front teeth)
Most common accidents:
o Falls
o Bike/Car accidents
o Sports related injuries
o Violence (at school)
o Abuse
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If severe refer student for physical exam:
o Neurological assessment
o Loss of consciousness
o Nausea/Vomiting
o Headache
o Lethargy
o Seizures
o Vision problems
o Tetanus exposure
• 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
• Soft tissue laceration - injury resulting in cut
or break in skin or soft tissue
socket
• 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
- 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
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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
• 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
• 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
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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
• 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
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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
- 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
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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
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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)
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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
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Professional care
• Ask about dental home
• Make dental referrals
• Get familiar with community resources for children’s oral health
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Diet
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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
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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 controlledrandomized trial. Dent Traumatol. 2012 Aug;28(4):263-7.
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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
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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 debonded band or bracket
Placing wax over site is a quick fix
Patient should see orthodontist treating them for help
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risk of:
• Infection
• Chipped teeth
• Gingival recession
Drew Barrymore
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.
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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.
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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.
Question
% Yes
% No
Have 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 28%
you not to use tobacco?
61%
During the past year did your parents talk with you about
not using?
58%
*Data for 6th-10th graders
39%
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31% reported it would be “Very easy” to get cigarettes
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64% reported they thought tobacco companies are trying to get
underage people to smoke
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6.5% reported that they tried to quit on their own or cold turkey
in the past year
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32% reported that someone they live with smokes cigarettes
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School-based Health Clinics can offer an array of oral health
services that will benefit adolescents
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School-based Health Clinic staff can be knowledgeable
about various oral health problems afflicting adolescents
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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
(My own picture of Vail)
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California Dental Association
Perinatal Oral Health Practice Guidelines
Available at: www.cdafoundation.org/learn/perinatal_oral_health
New York State Department of Health
Oral Health Care During Pregnancy and Early Childhood Practice Guidelines
Available at:
www.health.state.ny.us/publications/0824.pdf