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Pediatric Oral Health

Pediatric Oral Health. Bob Selvester, MD LCDR MC USN Family Physician Interservice Physician Assistant Program. 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 52% aged 6 to 8 years 67% aged 12 to 17 years.

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Pediatric Oral Health

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  1. Pediatric Oral Health Bob Selvester, MD LCDR MC USN Family Physician Interservice Physician Assistant Program

  2. 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 • 52% aged 6 to 8 years • 67% aged 12 to 17 years

  3. Learning Objectives • State the key components of a primary care oral health history and physical examination. • State the recommended intervals for examination by a Dental Health professional. • Recognize indications for referral

  4. AAPA/PAEA/NCCPA/ARC-PA • Do not address expectations for oral health except to say there must be training in all body systems

  5. AAFP • Dietary fluoride supplements should be considered for children from ages 6 months through 16 years when drinking water levels are suboptimal. • The AAFP recognizes avoidance of tobacco products by children and adolescents is desirable. • The effectiveness of physician advice and counseling in this area is uncertain.

  6. USPSTF Recommendations • Evidence is insufficient to recommend for or against routine risk assessment of preschool children by primary care clinicians for the prevention of dental disease (Rating I) • Primary care clinicians prescribe oral flouride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source is deficient in flouride. (Rating B)

  7. AAP Prior to 2000, initial exam by Dentist was recommended at age of 3.

  8. The American Academy of Pediatrics Oral Health Initiative The American Academy of Pediatrics Oral Health Initiative Wendy Nelson Manager Oral Health Initiative January 25, 2008 www.aap.org/oralhealth

  9. View the training online at www.aap.org/oralhealth/cme.

  10. Background

  11. Factors Necessary for Caries

  12. Brief Pathophysiology • Cariogenic Bacteria • Frequency of exposure • Contact time • Acidity

  13. Oral Flora: How Does Infection Occur? • Transmitted mainly from mother or primary caregiver to infant • Window of infectivity is first 2 years of life • Earlier child colonized, the higher the risk of caries

  14. 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) are major sources of “hidden” sugars. • High sugar content in sodas is a source of these substrates.

  15. Fluoride’s Influence on Oral Flora • Promotes remineralization of enamel, and may arrest or reverse early caries • Decreases enamel solubility • Inhibits the growth of cariogenic organisms, thus decreasing acid production • Concentrated in dental plaque • Primarily topical even when given systemically

  16. Not Just What You Eat, But How Often • Acids produced by bacteria after sugar intake persist for 20 to 40 minutes. • Frequency of sugar ingestion is more important than quantity.

  17. Substrate: Environmental Influences • Saliva inhibits bacterial growth. • Unremoved plaque promotes the caries process. Red disclosing tablet reveals plaque

  18. AAP Recommendations for an Oral Health Risk Assessment • Assess mothers’/caregiver’s oral health. • Assess oral health risk of infants and children. • Recognize signs and symptoms of caries. • Assess child’s exposure to fluoride. • Make timely referral to a dental home. • Provide anticipatory guidance including oral hygiene instructions (brush/floss).

  19. History

  20. High-Risk Groups for Caries • Children with special health care needs • Children from low socioeconomic and ethnocultural groups • Children with suboptimal exposure to topical or systemic fluoride • Children with poor dietary and feeding habits • Children whose caregivers and/or siblings have caries

  21. 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

  22. Examination

  23. Positioning Child for Oral Examination • Position the child in the caregiver’s lap facing the caregiver. • Sit with knees touching the knees of caregiver. • Lower the child’s head onto your lap. • Lift the lip to inspect the teeth and soft tissue.

  24. Primary Teeth Eruption

  25. Check for Normal Healthy Teeth

  26. Check for Early Signs of Decay: White Spots

  27. Check for Later Signs of Decay: Brown Spots

  28. Check for Advanced/Severe Decay

  29. Assessment

  30. AAPD Caries Risk Assessment Tool (CAT) Caries Risk Indicators Chart based on the AAPD Caries-Risk Assessment Tool. For more information on using the tool, refer to http://www.aapd.org/foundation/pdfs/cat.pdf.

  31. Referral

  32. Initial Screening by Child Dental Professional • By 12 months of age or 6 months after eruption of first tooth (whichever is sooner)—even natal teeth . . . • All children at “High Risk”—as early as 6 months of age. (earlier) • Any child with visible caries, plaque, or decay (right away)

  33. Referral: Establishment of Dental Home What is a dental home? When to refer? • Refer high-risk children by 6 months. • Refer all children by 1 year.

  34. Anticipatory Guidance

  35. Anticipatory Guidance • Minimize risk of infection. • Optimize oral hygiene. • Reduce dietary sugars. • Remove existing dental decay. • Administer fluorides judiciously.

  36. Xylitol for Mothers/Children Xylitol gum or mints used 4 times a day may prevent transmission of cariogenic bacteria to infants. • Helps reduce the development of dental caries • A “sugar” that bacteria can’t use easily • Resists fermentation by mouth bacteria • Reduces plaque formation • Increases salivary flow to aid in the repair of damaged tooth enamel

  37. Substrate: Contributing Dietary and Feeding Habits • Frequent consumption of carbohydrates, especially sippy cups/bottles with fruit juice, soft drinks, powdered sweetened drinks, formula, or milk • Sticky foods like raisins/fruit leather (roll-ups), and hard candies • Bottles at bedtime or nap time not containing water • Dipping pacifier in sugary substances

  38. Optimizing Oral Hygiene: Flossing When to Use Floss • Once a day (preferably at night) • Whenever any 2 teeth touch

  39. Toothbrushing Recommendations

  40. Toothpaste and Children • Children ingest substantial amounts of toothpaste because of immature swallowing reflex. • Early use of fluoride toothpaste may be associated with increased risk of fluorosis. • Once permanent teeth have mineralized (around 6-8 years of age), dental fluorosis is no longer a concern.

  41. Toothpaste A small pea-sized amount of toothpaste weighs 0.4 mg to 0.6 mg fluoride, which is equal to the daily recommended intake for children younger than 2 years.

  42. Example of Fluorosis Mild Fluorosis Severe Fluorosis

  43. Fluoride Concentration in Community Drinking Water Age <0.3 ppm 0.3–0.6 ppm >0.6 ppm 0–6 months None None None 6 mo–3 yrs 0.25 mg/day None None 3 yrs–6 yrs 0.50 mg/day 0.25 mg/day None 6 yrs–16 yrs 1.0 mg/day 0.50 mg/day None Recommended Fluoride Supplement Schedule MMWR: Recommendations for Using Fluoride to Prevent and Control Dental Caries in the US: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5014a1.htm.

  44. CME Credit Take this training online to earnContinuing Medical Education credit!http://www.aap.org/oralhealth/cmeQuestions about this training?E-mail oralhealthinfo@aap.org.

  45. Photo Credits Special thanks to the following individuals and organizations for contributing to this training: AAP Breastfeeding Initiatives American Academy of Pediatric Dentistry American Dental Association ANZ Photography Suzanne Boulter, MD George Brenneman, MD Content Visionary Melinda Clark, MD Joanna Douglass, BDS, DDS Rani Gereige, MD Donald Greiner, DDS, MSc Indian Health ServiceMartha Ann Keels, DDS Sunnah Kim Cynthia Neal, DDS Rama Oskouian, DMD P&G Dental ResourceNet Michael San Filippo Gregory Whelan, DDS

  46. Credits Primary Authors Suzanne Boulter, MD, FAAP Paula Duncan, MD, FAAP Kevin Hale, DDS Martha Ann Keels, DDS, PhD David Krol, MD, MPH, FAAP Wendy Mouradian, MD, MS, FAAP Wendy Nelson, ACCE Additional Contributors Betty Crase, IBCLC, RLC Martin J Davis, DDS Adriana Segura Donly, DDS, MS Rocio B Quinonez, DMD, MS, MPH Kathleen Marinelli, MD, IBCLC, FAAP Special thanks to the following individuals for contributing to the development of this training:

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