1 protecting all children’s teeth oral health in adolescence

1 www.aap.org/oralhealth/pact

Protecting All Children’s Teeth

Oral Health in Adolescence


Introduction

Continued focus on oral health during the adolescent period isimportant.

Many childhood risk factors persist and new oral health risk factorsmay emerge during adolescence. Opportunities exist to prepare,educate, and empower adolescents to take control of their oralhealth as they move toward adulthood.

Because adolescents often have an increased focus on personalaesthetics, this can provide an opening to discuss oral healthknowledge and behaviors during office visits.


Learner Objectives

Upon completion of this presentation, participants will be able to:

List common risk factors for dental caries during adolescence. Define periodontitis and gingivitis and state clinical signs, risk

factors, and anticipatory guidance regarding periodontal disease.

Discuss the prevalence of tobacco use among US adolescents and oral effects of tobacco.

Recall the adverse oral effects of methamphetamines and marijuana.

List common signs of oral cancer. Cite the AAP and AAPD stand on oral piercings and counsel a

patient on the risks associated with oral piercings.


Dental Caries

52% of 12- to 19 year olds have experienced tooth decay in at least 1 tooth and 13% of adolescents have untreated caries.

The pit and fissure surfaces of the molars are the most common site of caries.

The dynamic caries balance continues throughout adolescence, and the same factors that influence caries risk in children still exist in adolescence.


Dental Caries, continued

Health care providers should be mindful of the following risk factors for dental caries in adolescents:

Inadequate access to fluoride (especially topical fluoride) Poor oral hygiene Frequent access to sugars and acids

Sweetened sugar beverages including soda, sports drinks and juice Sugared beverage consumption is also a risk for obesity and osteoporosis

(especially in females) Sour candy and sticky snacks

Previous caries experience Reduced salivary flow


Dental Caries, continued

Special health care needs Infrequent professional dental care Risk factors that may first be noted in the adolescent, include

eating disorders and orthodontic appliances that make performing

oral hygiene more difficult


Anticipatory Guidance

Anticipatory guidance in caries prevention for adolescents is similar

to that of young children:

Encourage fluoridated water intake. Recommend fluoride supplementation for high risk teens not

having access to fluoridated water (up to age 16). Encourage fluoridated toothpaste use twice a day. Encourage daily flossing.


Anticipatory Guidance, continued

Encourage and assist in referrals for dental visits that can provide preventive strategies such as dental sealants, topical fluoride, plaque and calculus removal, and restorative measures.

Promote a healthy diet with rare snacking on sugary or acidic foods and liquids. Counsel on risk of vending machine options as these are often placed in locations that teens frequent.

Encourage and empower parental assistance in oral hygiene for adolescents with special health care needs.


Gingivitis

Gingivitis is gingival (gum) inflammation due to the build-up of plaque on tooth surfaces.

Symptoms of gingivitis include red and swollen gums that easily bleed withbrushing or flossing.

Gingivitis is usually the result of suboptimal oral hygiene, both inadequate brushing and flossing.

Antonio Moretti, DDS, MS Associate Professor, Department of Periodontology. UNC School of Dentistry

10www.aap.org/oralhealth/pact

Periodontitis

Periodontitis is usually accompanied by gingivitis but is a distinct disease process that involves irreversible destruction of the supporting tissues surrounding the tooth, including the alveolar bone.

Plaque and tartar accumulate at the gum line and the resultant inflammation leads to formation of a “periodontal” pocket between the gums and the teeth.

The infection and inflammation spread from the gingiva to the periodontal ligament and alveolar bone that support the teeth. The destruction of support causes the teeth to become mobile and, if left untreated, can lead to tooth loss.


Signs and Symptoms of Periodontal Disease

Gums that are swollen, bright red,

and tender to touch Gums that bleed easily Gingival recession Tooth Loss Loose/mobile permanent teeth Both hormonal changes and external

factors can affect the periodontal

tissues of the adolescent

Gingival Recession(affecting the mandibular anterior teeth)

Antonio Moretti, DDS, MS Associate Professor, Department of Periodontology. UNC School of Dentistry

Localized Aggressive Periodontitis

Usually begins at onset of puberty Alveolar bone loss usually affects incisors and 1st molars Destruction of supporting tissues = high risk for tooth loss Signs can include tooth mobility and migration (increased

spacing between teeth) Can occur without obvious inflammation (gingivitis) or other signs/symptoms Disease typically progresses very quickly Clinical and radiographic exam by a dental team is very important


Intra-oral condition is not necessarily linked to any systemic disease Genetic predisposition (family dental history should be evaluated; siblings should be examined) Destruction can either arrest or progress and affect more teeth and become “Generalized Aggressive Periodontitis” (can affect the entire dentition) A specific group of bacteria have been associated with this disease, so dental treatment typically includes antimicrobial therapy

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Photos courtesy of:Antonio Moretti, DDS, MS Associate Professor, Department

of Periodontology. UNC School of Dentistry

Arrows indicate sites with significant alveolar bone loss


Risk Factors for Periodontal Disease

Poor oral hygiene resulting in plaque and calculus formation Gingivitis or gingival recession

Can be triggered by abrasions from oral piercings Systemic conditions:

Down syndrome Immunodeficiency (e.g., cyclic neutopenia, leukocyte adhesion

deficiency) Metabolic diseases (e.g., diabetes, hypophosphatasia) Oncologic (e.g., leukemia, Langerhans cell histiocytosis)

Tobacco or marijuana use Pregnancy and hormonal contraceptives Oral trauma

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Periodontal Link to Systemic Disease

• Periodontitis may be an independent risk factor for: • Cardiovascular disease (stroke and coronary heart disease) • Diabetes (glycemic control, diabetes complications, and development

of type 2 diabetes) • Adverse pregnancy outcomes (i.e., low-birth weight, premature birth)

• Association with multiple other systemic diseases (cancer, arthritis,obesity, metabolic syndrome, chronic kidney disease) has been studied, but study size, limitations, and confounders prohibit statement of causal connection at this time. • Additional studies are warranted to investigate these associations.



Periodontal Disease Prevention and Treatment

Reinforce the importance of good oral hygiene, encourage brushing and flossing. Discourage all forms of tobacco and other drug use. Discuss the risks of oral piercings. Promote regular preventive dental visits. Maintain vigilance regarding the oral health of adolescents with special health care needs. Incorporate an evaluation of hard and soft oral tissues into every routine physical examination. Refer patients with abnormalities to a dental professional and continue close monitoring.


Trauma

Adolescents are at increased risk for trauma to the mouth and teeth because of their active lifestyle and increased risk-taking behaviors.

Oral and facial trauma can occur secondary to falls, violence, athletics, or motor vehicle and other accidents.


Risk Factors for Oral Trauma

Compromised protective reflexes or poor coordination (children

with special health care needs)

Lack of use of protective face and mouth gear for athletes

Substance abuse (by the adolescent or within the family)

Child abuse or neglect

Malocclusion with protruding front teeth

Hyperactivity

Oral piercings


Tobacco

Consider the prevalence of tobacco use among teenagers in the United States (2009 study): 26% of high school students report some tobacco use (cigarettes,

smokeless tobacco, cigars). 19.5% of high school students were current cigarette smokers. 14% of high school students reported cigar use. 8.9% of all high school students used smokeless tobacco.


Oral Effects of Tobacco

Tobacco has a direct carcinogenic effect on the epithelial cells of the oral mucous membranes and may cause oral cancer.

Tobacco can also have the following oral effects:

Tooth stains and discoloration

Halitosis

Calculus formation

Encouraging patients to quit smoking or using chewing tobacco can have positive effects on both their general and oral health.


Illicit Drugs

Illicit drug use can have negative effects on oral health by affecting salivary flow, changing the acidity of the mouth, and by promoting poor dietary habits and laxity in oral hygiene.


Methamphetamines

Street names: Crystal meth, meth, speed, ice, crank. Potent central nervous system stimulant that stimulates release and blocks re-uptake of monoamines in the brain. Can be smoked, snorted, injected, or taken orally. Rampant caries progression, termed meth mouth, may result from a combination of drug-induced xerostomia, increased consumption of high calorie, sugared, carbonated beverages, tooth grinding and clenching, and poor oral hygiene.


Meth Mouth

Signs of “meth mouth” include:

1. Accelerated tooth decay in teens and young adults.

2. Distinctive pattern of decay on buccal smooth surface of teeth and interproximal surfaces of anterior teeth.

3. Malnourished appearance of user. Used with permission from the American Dental Association


Meth Mouth, continued

If meth mouth is discovered:

1. Encourage the patient to stop using the drug, ask if they would

like help quitting, and assist them in finding help.

2. Encourage good oral hygiene.

3. Refer to a dentist for evaluation and management.


Cannabis

The oral health effects of cannabis are similar to tobacco and include: Gingivitis and periodontal disease Oral cancer Xerostomia


Oral Cancer

Approximately 30,000 Americans are diagnosed annually with oral cancer. In the 15-24 age group, there are 30 deaths per year.

Approximately 75% of oral cancers are related to tobacco use, alcohol use, or both.

Tobacco use in any form (cigarettes, cigars, chewing tobacco) can cause oral cancer.


Signs and Symptoms of Oral Cancer

1. Oral tenderness, burning, or a sore that does not heal2. Pain, tenderness, or numbness in the mouth3. Lump in the mouth4. Color changes in the mouth 5. Difficulty chewing, swallowing, or speaking 6. Change in the way the teeth fit together 7. Leukoplakia

Providers should encourage and assist in tobacco cessation, as well asexamine the oral mucosa for abnormalities, especially in tobacco-usingpatients.


Oral Piercings and Grills

The American Dental Association and the American Academy of Pediatric Dentistry have officially recommended against intraoral/perioral piercing and tongue splitting because of the potential for numerous negative sequelae.


Procedure-Related Risks

Swelling Infection

Oral piercing carries a risk for infection due to trauma of the skin or oral tissues and the vast amount of bacteria in the mouth.

Blood-borne disease transmission - Possible transmission of Hepatitis B, C, D, or G if the procedure is performed in non-sterile manner.

Endocarditis Oral piercing is a route of entry of bacteria into the bloodstream May result in endocarditis for patients with cardiac abnormalities

Prolonged bleeding and possible nerve damage


Jewelry-Related Complications

Injury to the gums. Chipped (fractured) teeth Interference with normal oral function. Allergic reaction/hypersensitivity to metal (eg, nickel). Interference with oral health evaluation. Aspiration or ingestion possible if

jewelry becomes loose.

Used with permission from the Martha Ann Keels, DDS, PhD; Division Head of Duke Pediatric Dentistry, Duke Children's Hospital


Grills

No studies show that grills are harmful to the mouth. However, there is at least one case report of a grill accelerating the caries process in an adolescent.

Grill wearers should be counseled to: Remove the grill when eating. Limit the amount of time the grill is worn. Brush and floss carefully. Watch for symptoms of allergy to the grill's metal.

Used with permission from the © American Academy of Pediatric Dentistry (AAPD); Reproduced with AAPD permission


Question #1

Which of the following is a risk factor for caries in adolescents?

A. Poor oral hygiene B. Inadequate access to topical fluoride C. Previous caries experienceD. Frequent access to sugarsE. All of the above


Answer

Which of the following is a risk factor for caries in adolescents?

A. Poor oral hygieneB. Inadequate access to topical fluorideC. Previous caries experienceD. Frequent access to sugarsE. All of the above


Question #2

Which of the following is not a sign or symptom of periodontal disease? A. Loose teethB. LeukoplakiaC. HalitosisD. Swollen gumsE. Gums that bleed easily


Answer

Which of the following is not a sign or symptom of periodontal disease? A. Loose teethB. LeukoplakiaC. HalitosisD. Swollen gumsE. Gums that bleed easily


Question #3

Which of the following behaviors can affect salivary flow andchange the acidity of the mouth? A. Oral piercings B. Using tobaccoC. Using illicit drugsD. Wearing a grill E. All of the above


Answer

Which of the following behaviors can affect salivary flow andchange the acidity of the mouth? A. Oral piercings B. Using tobaccoC. Using illicit drugsD. Wearing a grillE. All of the above


Question #4

True or False? Approximately 30% of high school students are smokers. A. True B. False


Answer

True or False? Approximately 30% of high school students are smokers. A. True B. False


Question #5

Which of the following can cause gingivitis? A. PregnancyB. SmokingC. Certain medicationsD. All of the aboveE. None of the above

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References

1. American Academy of Pediatric Dentistry. Guideline on Adolescent Oral Health Care. AAPD Reference Manual. 2005-2006. P. 72-79.

2. American Academy of Pediatric Dentistry. Policy on Intraoral/Perioral Piercing and Oral

Jewelry/Accessories. Revised 2011. Reference Manual. 35 (6): 65-66. Accessed December 20, 2013.

3. American Academy of Pediatric Dentistry. Periodontal Diseases of Children and Adolescents.

Reference Manual. 2004; 35(6): 338-345.

3. American Dental Association. Grills, “grillz”, and fronts. JADA. 2006; 137:1192. 4. American Dental Association. Oral piercing and health. JADA. 2001; 132:127. 5. Borgnakke W, Ylostalo P, Taylor G. et al. Effect of periodontal disease on diabetes: Systematic review of epidemiologic observational evidence. J Periodontol. 2013; 84(4 Suppl): 135–152.6. Brown LJ, Brunelle JA, Kingman A. Periodontal status in the United States, 1988-1991: prevalence, extent and demographic variations [special issue]. J Dent Res. 1996; 75:672-83 7. Campbell A, Moore A, Williams E, Stephens J, Tatakis DN. Tongue piercing: impact of time and barbell stem length on lingual gingival recession and tooth chipping. J Periodontology. 2002; 73(3):289-297.

References

8. Casamassimo P. Bright futures in practice: Oral health. Arlington, VA. National Center for Education in Maternal and Child Health. 1996. 9. CDC. Youth Risk Behavior Surveillance, United States – 2009, Surveillance Summaries, June 4. MMWR 2010; 59(No. SS-5). 10. Dietrich T, Sharma, P, Walter, C et al. The epidemiological evidence behind the association between periodontitis and incident atherosclerotic cardiovascular disease. J Periodontol. 2013; 84 (Suppl 4), 70–84.11. Hollowell WH, Childers NK. A New Threat to Adolescent Oral Health: The Grill. Pediatr Dent. 2007; 29(4): 320-2.12. Howe AM. Methamphetamine and childhood and adolescent caries. Aust Dent J. 1995; 40(5):340. 13. Ide M, Papapanou PN. Epidemiology of association between maternal periodontal disease and adverse pregnancy outcomes - systematic review. J Periodontol. 2013. 84(4 Suppl): 181–194.14. Kapferer I, Beier US, Persson RG. Tongue Piercing: The Effect of Material on Microbiological Findings. Journal of Adolescent Health. 2011; 49(1):76-83.

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References, continued

15. Linden GJ, Lyons A, Scannapieco FA. Periodontal systemic associations: review of the evidence. J Periodontol. 2013; 84(Suppl 4):S8-S19.16. Ludwig DS, Peterson KE, Gormaker SL. Relation between consumption of sugar-sweetened drinks and childhood obesity: A prospective, observational analysis. Lancet. 2001; 357(9255): 505-8.17. Oh TJ, Eber R, Wang HL. Periodontal diseases in the child and adolescent. J Clin Periodontol. 2002; 29(5):400-10.18. The Society of Teachers of Family Medicine. Smiles for Life: A national oral health curriculum. Available online at: wwwsmilesforlifeoralhealth.org. Accessed May 25, 2013. 19. US Department of Health and Human Services. Oral health in America: A Report of the Surgeon General. Rockville MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. Available online at www.nidcr.nih.gov/DataStatistics/SurgeonGeneral. Accessed January 18, 2013. 20. Wyshak G. Teenaged girls, carbonated beverage consumption, and bone fractures. Arch Pediatr Adolesc Med. 2000; 154(6):610-3.

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