AAP Oral Health Initiative

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The American Academy ofPediatrics

Oral Health Initiative

Wendy Nelson

Manager Oral Health Initiative

January 25, 2008

The American Academy ofPediatrics

Oral Health Initiative

www.aap.org/oralhealth
http://www.aap.org/oralhealthhttp://www.aap.org/oralhealthhttp://www.aap.org/oralhealth


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Oral Health Risk Assessment:Training for Pediatricians and Other Child Health Professionals

Developed by the American Academy of PediatricsOral Health Initiative

Supported in part by the Maternal and Child Health Bureau,Health Resources and Services Administration

Department of Health and Human ServicesU93MC00184

View the training online at www.aap.org/oralhealth/cme.
http://www.aap.org/oralhealth/cmehttp://www.aap.org/oralhealth/cme


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Outline

Overview of Dental Caries and Early Childhood Caries

Pathophysiology of Caries Process

History: Determining Caries Risk

Physical: Oral Health Assessment

Anticipatory Guidance

Treatment and Referral

This training includes the following sections:


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Child Health Professionals Role inPromoting Oral Health

See children earlyand regularly.

Become experts in oral

health preventionstrategies.

Advocate for child

health: Oral health ispart of overall health!


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AAP Recommendations for anOral Health Risk Assessment

Assess mothers/caregivers oral health.

Assess oral health risk of infants andchildren.

Recognize signs and symptoms of caries.

Assess childs exposure to fluoride.

Provide anticipatory guidance includingoral hygiene instructions (brush/floss).

Make timely referral to a dental home.


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Learning Objectives

Understand the role of the childhealth professional in assessingchildrens oral health.

Understand the pathogenesisof caries.

Conduct an oral health riskassessment.

Identify prevention strategies.

Understand the need forestablishing a dental home.

Provide appropriate oral health education to families.


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Overview of Dental Caries andEarly Childhood Caries

Prevalence of Dental Caries

Early Childhood Caries

Early Childhood Caries CanLead to

Consequences of Dental Caries

This section addresses the following topics:


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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




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Early Childhood Caries

Affects teeth that erupt first,

and are least protected by saliva

Initial lesionswhite decalcificationwith beginning enamel breakdown

Late stage lesionsmoderate to severeenamel and dentin destruction

A severe, rapidly progressingform of tooth decay in infantsand young children


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Early Childhood Caries Can Lead to

Extreme pain

Spread of infection

Difficulty chewing, poor weight gain

Falling off the growth curve Extensive and costly dental

treatment

Risk of dental decay in adult teeth

Crooked bite (malocclusion)


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Consequences of Dental Caries

Missed school days Impaired language development

Inability to concentrate in school

Reduced self-esteem

Possible facial cellulitis requiringhospitalization

Possible systemic illness forchildren with special health

care needs


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Pathophysiology of Caries Process

Factors Necessary for Caries

Tooth

Oral Flora

Oral Flora: Pathogenesis of Caries

Oral Flora: How Does Infection Occur?

Fluorides Influence on Oral Flora

Substrate: You Are What You Eat

Substrate: Environmental Influences

Not Just What You Eat, But How Often



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Oral Flora

Normal oral flora = billionsof bacteria.

Intraoral bacterialcolonization occurs beforethe eruption of the firsttooth.


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Oral Flora:Pathogenesis of Caries

An infectious process

Initiated by pathogenic bacteriaStreptococcusmutansand Streptococcus sobrinus


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Oral Flora:How Does Infection Occur?

Transmitted mainly frommother or primary caregiverto infant

Window of infectivity is first2 years of life

Earlier child colonized, the

higher the risk of caries


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Fluorides Influence on Oral Flora

Promotes remineralization of enamel,and may arrest or reverse early caries

Decreases enamel solubility

Inhibits the growth of cariogenicorganisms, thus decreasing acidproduction

Concentrated in dental plaque

Primarily topical even when given systemically


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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) aremajor sources of hidden sugars.

High sugar content in sodas is a

source of these substrates.


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Not Just What You Eat, But How Often

Acids produced by bacteria after sugar intake persist for20 to 40 minutes.

Frequency of sugar ingestion is more important thanquantity.


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Breastfeeding

The AAP and AAPD stronglyendorse breastfeeding.

Although breastmilk aloneis not cariogenic, it may be

when combined with othercarbohydrate sources.

For frequent nighttimefeedings with anything but water after tooth eruption,

consider an early dental home referral.


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History: Determining Caries Risk


High-Risk Groups for Caries

Children With Special HealthCare Needs (CSHCN)

Common Issues Among ChildrenWith Special Health Care Needs

Socioeconomic Factors

Ethnocultural Factors

Fluoride Exposure


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High-Risk Groups for Caries

Children with special health care needs

Children from low socioeconomic andethnocultural groups

Children with suboptimal exposure to topicalor systemic fluoride

Children with poor dietary and feeding habits

Children whose caregivers and/or siblingshave caries

Children with visible caries, white spots,plaque, or decay


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Children With Special Health Care Needs(CSHCN)

Be aware of oral health problems orcomplications associated with medicalconditions.

Monitor impact of oral medications andtherapies.

Choose nonsugar-containing medicationsif given repeatedly or for chronicconditions.

Refer early for dental care (before or byage 1 year).

Emphasize preventive measures.

Recommendations for Child Health Professionals:

Damage caused by holdingmedications in mouth


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Common Issues Among Children WithSpecial Health Care Needs

Children with asthma and allergies areoften on medications that dry salivarysecretions, increasing risk of caries.

Children who are preterm or low birth

weight have a much higher rate ofenamel defects and are at increasedrisk of caries.

Children with congenital heart diseaseare at risk for systemic infection from

untreated oral disease.


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Socioeconomic Factors

The rate of early childhood dental caries is near epidemic proportions in

populations with low socioeconomic status.

No health insurance and/or dental insurance

Parental education level less than high

school or GED

Families lacking usual source of dental care

Families living in rural areas


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Ethnocultural Factors

Increased rate of dentalcaries in certain ethnicgroups

Diet/feeding practices andchild-rearing techniquesinfluenced by culture


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Physical: Oral Health Assessment


Maternal Primary Caregiver Screening Child Oral Health Assessment

Positioning Child for Oral Examination

Primary Teeth Eruption

What to Look For

Check for Normal Healthy Teeth

Check for Early Signs of Decay: White Spots

Check for Early Signs of Decay: Brown Spots

Check for Advanced/Severe Decay

AAPD Caries Risk Assessment Tool (CAT)


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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


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Maternal/Primary Caregiver Screening

Assess mothers/caregivers oralhistory.

Document involved quadrants.

Refer to dental home ifuntreated oral health disease.


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Child Oral Health Assessment

Prepare for the Examination

Provide rationale.

Describe caregiver role.

Ensure adequate lighting.

Assemble necessary

equipment.


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Positioning Child for Oral Examination

Position the child in thecaregivers lap facing the caregiver.

Sit with knees touching theknees of caregiver.

Lower the childs head ontoyour lap.

Lift the lip to inspect the teeth

and soft tissue.


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Primary Teeth Eruption


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What to Look For

Lift the lip to inspect soft tissue and teeth.

Assess for

- Presence of plaque

- Presence of white spots or dental decay

- Presence of tooth defects (enamel)- Presence of dental crowding

Provide education on brushing and dietduring examination.


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Check for Normal Healthy Teeth


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Check for Early Signs of Decay: White Spots


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Check for Later Signs of Decay: Brown Spots


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Check for Advanced/Severe Decay



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This chart was adapted (with permission) from a similar chart developedby the American Academy of Pediatric Dentistry. For more information onusing this type of tool, refer tohttp://www.aapd.org/foundation/pdfs/cat.pdfand http://www.aapd.org/media/policies_guidelines/p_cariesriskassess.pdf .

Low Risk Moderate Risk High Risk

ClinicalConditions

- No carious teeth inpast 24 months

- No enameldemineralization

(enamel caries white-spot lesions)

- No visible plaque; nogingivitis

- Carious teeth in the past 24months

- 1 area of enamel demineralization(enamel caries white-spot lesions)

- Gingivitis

- Carious teeth in the past 12 months

- More than 1 area of enameldemineralization (enamel caries white-spot lesions)

- Visible plaque on anterior (front) teeth

- Radiographic enamel caries

- High titers of mutans streptococci

- Wearing dental or orthodonticappliances

- Enamel hypoplasia

Environmental

Characteristics

- Optimal systemic andtopical fluoride exposure

- Consumption of simplesugar or foods stronglyassociated with cariesinitiation primarily atmealtimes

- Regular use of dentalcare in the establisheddental home

- Suboptimal systemic fluorideexposure with optimal topical

exposure

- Occasional between mealexposures to simple sugar or foodsstrongly associated with caries

- Mid-level caregiver socioeconomicstatus (ie, eligible for school lunchprogram or SCHIP)

- Irregular use of dental services

- Suboptimal topical fluoride exposure

- Frequent (ie, 3 or more) between-mealexposures to simple sugars or foodsassociated strongly with caries

- Low-level caregiver socioeconomicstatus (ie, eligible for Medicaid)

- No usual source of dental care

- Active caries present in the mother

General HealthConditions

- Children with special health care needs- Conditions impairing salivacomposition/flow

CariesR

iskIndicators
http://www.aapd.org/foundation/pdfs/cat.pdfhttp://www.aapd.org/media/policies_guidelines/p_cariesriskassess.pdfhttp://www.aapd.org/media/policies_guidelines/p_cariesriskassess.pdfhttp://www.aapd.org/foundation/pdfs/cat.pdf


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Anticipatory Guidance Minimize Risk for Infection

Xylitol for Mothers

Substrate: ContributingDietary and Feeding Habits

ToothbrushingRecommendations

Toothpaste and Children

Toothpaste

Optimizing Oral Hygiene: Flossing


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Minimize Risk for Infection

Address active oral healthdisease in mother/caregiver.

Educate mother/caregiverabout the mechanism ofcariogenic bacteria

transmission.

Mother/caregiver should modelpositive oral hygiene behaviorsfor their children.

Recommend xylitol gum tomothers/caregiver.


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Minimize risk of infection.

Optimize oral hygiene.

Reduce dietary sugars.

Remove existing dental decay.

Administer fluorides judiciously.


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Xylitol for Mothers

Helps reduce the developmentof dental caries

A sugar that bacteria cant useeasily

Resists fermentation by mouthbacteria

Reduces plaque formation

Increases salivary flow to aid in therepair of damaged tooth enamel

Xylitol gum or mints used 4 times a day may prevent

transmission of cariogenic bacteria to infants.


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Substrate: Contributing Dietary and Feeding Habits

Frequent consumption of carbohydrates,

especially sippy cups/bottles with fruitjuice, soft drinks, powdered sweeteneddrinks, formula, or milk

Sticky foods like raisins/fruit leather(roll-ups), and hard candies

Bottles at bedtime or nap timenot containing water

Dipping pacifier in sugarysubstances


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Toothbrushing Recommendations

Age

Toothbrushing Recommendations(CDC, 2001)

< 1 year~ Clean teeth with soft toothbrush

12 years~ Parent performs brushing

26 years ~ Pea-sized amount of fluoride-containing toothpaste 2x/day

~ Parent performs or supervises

> 6 years ~ Brush with fluoridated

toothpaste 2x/day


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Toothpaste and Children

Children ingest substantialamounts of toothpaste becauseof immature swallowing reflex.

Early use of fluoride toothpaste

may be associated withincreased risk of fluorosis.

Once permanent teeth have mineralized (around 6-8 years ofage), dental fluorosis is no longer a concern.


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Toothpaste

A small pea-sized amount of toothpaste weighs0.4 mg to 0.6 mg fluoride, which is equal to the daily

recommended intake for children younger than 2 years.


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Optimizing Oral Hygiene: Flossing

When to Use Floss

Once a day(preferably at night)

Whenever any 2 teethtouch

T t t d R f l


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Treatment and Referral


Recommended FluorideSupplement Schedule

Example of Fluorosis

Fluoride Varnish

Applying Fluoride Varnish Remove Existing Dental Decay:

Treating an Infection

Referral: Establishment ofDental Home

Community Systems of Care


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Recommended Fluoride Supplement Schedule

None0.50 mg/day1.0 mg/day6 yrs16 yrs

None0.25 mg/day0.50 mg/day3 yrs6 yrs

NoneNone0.25 mg/day6 mo3 yrs

NoneNoneNone06 months

>0.6 ppm0.30.6 ppm


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Example of Fluorosis

Mild Fluorosis Severe Fluorosis


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Fluoride Varnish

5% sodium fluoride or 2.26% fluoride in a viscous resinous

base in an alcoholic suspension with flavoring agent (eg,bubble gum)

Has not been associated with fluorosis

Application does not replace the dental home nor is it

equivalent to comprehensive dental care


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Applying Fluoride Varnish

R E i ti D t l D


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Remove Existing Dental Decay:Treating an Infection


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Referral: Establishment of Dental Home

What is a dental home?

When to refer?

Refer high-risk children by 6months.

Refer all children by 1 year.


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Conclusion


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Conclusion

You Can Make a Difference!

CME Credit


Yo Can Make a Diffe ence!


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You Can Make a Difference! Institute oral health risk assessments

into well-child visits.

Provide patient education regardingoral health.

Provide appropriate prevention interventions(eg, feeding practices, hygiene).

Document findings and follow-up.

Train office staff in oral healthassessment.

Identify dentists (pediatric/general)in your area who accept newpatients/Medicaid patients.

Take a dentist to lunch to establish a

referral relationship. Investigate fluoride content in area water supply.

CME Credit


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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
http://www.aap.org/oralhealth/cmemailto:[email protected]:[email protected]://www.aap.org/oralhealth/cme


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Photo Credits

Special thanks to the following individuals and

organizations for contributing to this training:

AAP Breastfeeding InitiativesAmerican Academy of PediatricDentistryAmerican 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


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AAP Oral Health Initiative

Documents

Transcript of AAP Oral Health Initiative