Colorado Association of School-Based Health Care May 2, 2013

1. Oral Health Care and Adolescents: Latest Research and Clinical Implications Colorado Association of School-Based Health CareMay 2, 2013 Elizabeth Shick, DDS, MPH Assistant Professor, University of Colorado School of Dental Medicine

2. I have no relevant financial relationships with any commercial interests. (But I will shamelessly pull pictures from Google Images)

3. 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

4. The Problem 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

5. Coordinated School Health Programs #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

6. Resource: ASTDD School and Adolescent Oral Health Committee

7. 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

8. 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

13. 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

14. 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

15. 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

16. 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+)

17. 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??

19. 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

20. School Performance • 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.

21. Dental Caries • Review of dental anatomy • Progression of a cavity

22. Dental Emergencies Two basic types: • Trauma • Infection

23. In the news… Deamonte Driver 12 years old Prince Georges County, Maryland Died February 27, 2007 Cause of death: complications from dental infection Does anyone recognize him?

24. Oral evaluation Cavities or past dental treatment Facial swelling Abscess noted near gumline

25. Facial Swelling • Facial swelling accompanied by pain, limited opening and deviation on opening. • Evaluate if swelling is into orbit or will obstruct airway.

26. Toothache Algorithm Student presents with toothache No facial swelling Presence of facial swelling Urgent Not 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

27. Facial Swelling • 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

28. Facial Swelling • Antibiotics • 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 • IV • Unasyn 100-400 mg/kg/day in divided doses every 6 hours • Clindamycin 20-40 mg/kg/day in 3-4 divided doses

29. Treatment • Root canal therapy: • Provides drainage of infection via canal space and crown of tooth • Pulp is removed, canals are cleaned and disinfected and then filled with biocompatible material such as guttapercha or MTA (mineral trioxide aggregate) • Tooth usually requires a crown placed after that within 1 month of treatment ideal • >95% success rates for permanent teeth • Extraction: • Remove the sources of infection and provide drainage through the socket site • 100% successful

30. Dental Trauma

31. Dental Trauma • Most common site maxillary incisors (upper front teeth) • Most common accidents: • Falls • Bike/Car accidents • Sports related injuries • Violence (at school) • Abuse

32. Medical Clearance • If severe refer student for physical exam: • Neurological assessment • Loss of consciousness • Nausea/Vomiting • Headache • Lethargy • Seizures • Vision problems • Tetanus exposure

33. 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

34. 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

35. 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

36. Root Fracture • 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

37. 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

38. 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

39. Luxation - Extrusion • 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 looseor high pain level • If not corrected and bone re-ossifies can be very difficult to correct later

40. Lateral Luxation • Facial, lingual, mesial, distal luxationsmay 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 looseor high pain level

41. Avulsion • 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

42. 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 GOT MILK?

43. 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

44. 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)

45. 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

46. 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

47. 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 DuddyFA, Weissman J, Lee RA Sr, Paranjpe A, Johnson JD, CohencaN. nfluenceof different types of mouthguards on strength and performance of collegiate athletes: a controlled-randomized trial. Dent Traumatol. 2012 Aug;28(4):263-7.

48. 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

49. 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

50. Oral Piercings • Increased risk of: • Infection • Chipped teeth • Gingival recession Drew Barrymore PlessasA, PepelassiE. Dental and periodontal complications of lip and tongue piercing: prevalence and influencing factors. Aust Dent J. 2012 Mar;57(1):71-8.