Post on 15-Dec-2015
transcript
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
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 Emergencies
Two 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 % 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 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)