Pediatric Oral Health Risk Assessment
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  • Oral Health and Dental Public Health in South Carolina Timeline Prior to 2000, Dr. Waddell, SCDHEC Deputy Director of Health Services had been working to re-establish a state dental public health program at DHEC. In 2000, the US Surgeon General’s report on “Oral Health in America” not only recognized the importance of children's oral health but also identified the high incidence of dental cares in this population. In 2000, DHEC brought Dr. Ray Lala, a HRSA federal assignee to South Carolina as the director of the Oral Health Division. In 2002, SC was awarded the RWJF State Action for Oral Health Access Program funding for the More Smiling Faces project More Smiling Faces in Beautiful Places (MSF) is one of six oral health initiatives that are part of the State Action for Oral Health Access (SAOHA) Program that is funded by the Robert Wood Johnson Foundation (RWJ) and managed by the Center for Health Care Strategies. MSF is based upon partnerships under the leadership of the South Carolina Department of Health and Environmental Control (SCDHEC). Components of the program include: Creation of an integrated oral health network of dentists, physicians, nurse practitioners, dental hygienists, public and private health providers, community health centers, and churches to increase access to oral health care Provision of pediatric oral health training programs for medical and dental professionals Establishment of a system to link medical homes with oral health care providers, provide patients with resources, screen for eligibility in Medicaid or other insurance programs, and arrange patient transportation Provision of educational guidance and support to parents and families that enable them to become effective managers of their child’s oral health needs.
  • Significant advances in dentistry have not been equitable to all people. Dental caries is the most common chronic disease affecting children in the United States; five times more common than asthma and seven times more common than hay fever. - On August 26, 2005 the Centers for Disease Control and Prevention (CDC) released a new report in its Morbidity and Mortality Weekly Report (MMWR) surveillance summary titled, Surveillance for Dental Caries, Dental Sealants, Tooth Retention, Edentulism, and Enamel Fluorosis—United States, 1988-1994 and 1999- 2002 (available at: http://cdhp.org/newsbytes/newsbytes.asp) . Key finding: Dental caries trends are higher among the nation’s youngest children . 28% of Pre-school children ages 2 through 5 years have experienced tooth decay. This findings suggests that over 4 million children are affected nationwide – a jump of over 600,000 additional preschoolers over a decade. South Carolina 2001 Oral Health Needs Assessment - 1 out of 3 children in SC’s kindergartens have experienced untreated tooth decay. Dental disease persists despite the fact that it is preventable.
  • Early childhood caries (ECC) occurs in the primary teeth of infants and young children. ECC is often associated with the use of bottles at nap time and bedtime, this is not the exclusive cause.
  • Oral health disparities impact poor children Low-income children have the greatest odds of having tooth decay, have the most severe experience with tooth decay, and are most likely to have untreated cavities. Children ages 2-11 in families with income under $18,0002 were nearly twice as likely to experience decay as children in families with twice that income level (55% versus 31%). Decay severity was more than twice as great for poor children as their higher income peers. Children in poverty were more than twice as likely to have untreated cavities as their higher income peers. Children of color are more likely to experience tooth decay and have their cavities untreated. Because children of color are the fastest growing subpopulation of children in the U.S., their higher caries experience CDHP Issue Brief Early Childhood Caries Trends Upward http://www.cdhp.org/CDHPPubs/IssuePolicyBriefs.asp
  • Opportunity for early intervention Pediatricians, family medicine physicians, nurse practitioners, physician assistants, registered nurses and other health professionals are more likely to reach new mothers and infants on a regular basis during infancy and early childhood than are dentists. Average child visits the medical provider 10 times in the first 3 years to receive both well child and sick care. Pediatric are focuses on preventive care and already has incorporated anticipatory guidance related to pediatric oral health such as diet, feeding practices, fluoride supplementation and injury prevention. Health professionals understand that oral health is part of a child’s overall health and are aware of the impact of dental diseases on a child health and well being.
  • Tooth decay in primary teeth predicts future tooth decay in permanent teeth as the child grows older. With the increase in tooth decay in preschool age children, we can expect and increase in tooth decay in their permanent teeth as the children get older. To keep this from happening, it is critical to identify children at greatest risk for caries as early as possible and initiate comprehensive dental treatment that is consistent with professional “age one dental visit” policies and establishment of the “dental home.” The challenge to the dental care system is significant as pre-school age children have the lowest rates of dental care of all age groups in the US and therefore currently miss an important and timely opportunity for effective prevention.
  • Policies: American Academy of Pediatrics, Section of Pediatric Dentistry. 2003. Oral health risk assessment timing and establishment of the dental home . Pediatrics 3(5):1113-1116. American Academy of Pediatric Dentistry. 2002. Policy on the use of a caries-risk assessment tool (CAT) for infants, children and adolescents . Pediatric Dentistry 24(7):15-17.
  • Caries begins as a streptococcal infection. In order to progress, Bacteria , predominately streptococcus mutans metabolize fermentable carbohydrates including sugars and starches to produce acid and therefore a low pH. Acid deminterializes or dissolves the tooth If the demineralization continues, the surface enamel is weakened with eventual cavitation or breakdown of the tooth surface As the demineralization continues, the decay spreads farther into the tooth
  • Exactly why an early oral assessment is so important.
  • The children of mothers with higher caries rate are at higher risk for dental caries Modification of mother’s oral flora at the time the infant’s colonization can significantly impact the child’s caries rate. Oral health risk assessment before 1 year of age offers an opportunity to identify high risk patients and provide timely referral and intervention for the child. Acquisition of S. mutans appears to take place through mouth-to-mouth transmission between caretaker and child. Transmission can be delayed/prevented by the initiation of a prevention program including meticulous oral hygiene, especially in caretakers who demonstrate a high-risk level of S. mutans www.dentalcare.com
  • Information adapted from the Policy on Use of a Caries-risk Assessment Tool (CAT) for Infants, Children and Adolescents. American Academy of Pediatric Dentistry .
  • The child is initially held by mother and slowly lowered into health professional’s lap. Child may cry, but that will allow you to see their teeth better. Some medical providers prefer positioning the child on the exam table and working from behind the head or have older children sit on the table. Ask mother to hold the child’s hands
  • For more information on Oral Development: http://www.mchoralhealth.org/PediatricOH/mod2_1.htm Common oral conditions and abnormalities: http://www.mchoralhealth.org/PediatricOH/mod3.htm
  • Healthy teeth are shiny and smooth. Arrows point to “white spots” or areas of demineralized enamel. Earliest signs of decay may appear as white spots or like frosted glass or flat paint. “White spots” can be remineralized with the use of fluoride varnish Brown or yellow spots or carious lesions on the teeth are more obvious signs of tooth decay The inside of the upper front teeth is where the baby bottle nipple rests. Once the disease is established and the decay goes through the enamel into the dentin, restorative care is required. Once a child has experienced tooth decay, follow ups is very important.
  • If you observe any signs of tooth decay, you can show them to the parent. Show parent how to lift the child’s upper lip while brushing the upper teeth and to routinely check the teeth for chalky white or brown spots, being sure to look at both the front and back of the teeth and near the gumline. White spots=early signs of decay. Child needs to see a dentist!
  • Slides from: www.dentalcare.com
  • Slides from: www.dentalcare.com
  • Slides from: www.dentalcare.com
  • Dental home: provides care of infants and children ideally that is accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective.
  • Other considerations are: May not be receiving adequate home care due to competing medical needs. Most babies and young children with SHCN are considered to be at “high risk” for tooth decay. Dilantin, medication for epilepsy and medications used to prevent transplant rejection can lead to gingival overgrowth (hypertrophy) which makes hygiene difficult and increases risk for gum disease.
  • Sit your baby on your lap, facing to one side Support the health with your arm and hand Use the index finger or thumb of your supporting hand to open the mouth and support the lower jaw Wrap the wet cloth around the index finger of your other hand Wipe the roof of the mouth, tongue, cheeks and gums Once teeth appear, clean with cloth or small soft toothbrush Breastfeeding should be encouraged and mothers should be advises that removing their baby from the breast and wiping their baby’s gums reduces the risk of tooth decay in baby teeth.
  • As baby gets bigger, you can trying sitting on the floor with the baby’s head in your lap
  • Young children have not developed good coordination, so you will need to help them until about age 8.The caregiver will evaluate the child’s motor activity to assess the child’s capabilities to brush effectively. The care giver should brush the child’s teeth after the child has completed brushing. Note: Caregiver’s hand is over the child’s hand. This allows the caregiver to teach the child proper brushing technique. This is an important part of teaching the child how to brush properly.
  • Any liquid except water — even milk and juice — can cause cavities. Some other ways to calm baby: Favorite blanket or toy Pacifier Holding, patting, rocking Softly singing or talking to baby
  • With obesity and diabetes on the rise in SC’ children, we have a responsibility to counsel families to limit both sugar intake and the frequency of exposures per day to enhance both general overall health as well as oral health.
  • The bacteria in the mouth use the sugar to make acids that can demineralize the tooth surface.
  • Children should receive supplements based on this table only after a determination of the FL content of their primary water source.
  • ADA approved FL containing toothpaste is recommended for children age two and over. Very small amount (pea sized) should be smeared on brush for use with very young children.
  • Fluoride varnish helps reverse early demineralization that has already started.
  • White spots are areas of demineralization and considered early decay—Indication for fluoride varnish applications.
  • Child is examined in a knee-to-knee position with parent.
  • Remember to clean and dry the teeth. It is critical to dry the teeth with a gauze before applying the varnish.
  • When fluoride varnish is used to remineralize white spot lesions these are the results. Acknowledgement: The fluoride varnish section was adapted wit permission from the work of Dr. Michael Kanellis, Department of Pediatric Dentistry, University of Iowa.
  • Oral Health Risk Assessment Training for Pediatricians and Other Child Health Professionals Developed by American Academy of Pediatrics Pediatrics Collaborative Care (PedCare) Program Supported by the Maternal and Child Health Bureau, Health Resources and Services Administration Department of Health and Human Services U93MC0
  • Fluoride prevents tooth decay by inhibiting the demineralization of the tooth surface-enamel, enhancing remineralization and inhibiting the bacteria in plaque. Water fluoridation is considered to one of the greatest public health advances of the 20 th century.
  • Fluoride toothpaste is effective at preventing dental caries.
  • It is important to address the limiting the frequency of simple carbohydrates including sugary foods and drinks, and foods like potato chips. It is the frequency of fermentable carbohydrate intake that contributes to tooth decay. For more information: http://ohioline.osu.edu/mob-fact/0001.html Nutritional information for pregnancy and for the child up to age three. Into the Mouths of Babes: A Nutritional Guide to Age Three Nutritional Needs of Pregnancy
  • Serious gum disease has been linked to premature and low birth weight babies. This visit gives the dental team the opportunity to assess the mother’s caries risk and subsequently the caries risk for her child.
  • Xylitol is a naturally occurring sugar. An over the counter brand is Carefreee Koolerz (1.6 grams piece). When purchasing over the counter xylitol products, one should look to see if xylitol is listed as the first ingredient. A therapeutic dose is 5-10 grams per day.
  • Get regular dental care because cavity germs in your mouth can be passed to your baby by sharing spoons, forks and cups. Learn how to do a Smile Check to check for white spots or stains on the teeth by lifting the baby’s upper lip. Learn how to clean your baby’s teeth by wiping the baby’s mouth and teeth with a clean, soft cloth or a baby toothbrush. To prevent baby bottle tooth decay do not put your baby in bed with a bottle at night or naptime. If you do use a bottle at night or naptime, fill it with water only. Teach you child how to use a cup around age one. Ask you doctor or dentist to check your child’s teeth by age one. Fluoride drops are important for babies starting at 6 months of age. Talk to your doctor or dentist about fluoride.

Transcript

  • 1. Pediatric Oral Health Risk Assessment Training for Medical Professionals More Smiling Faces in a SCDHEC led oral health initiative funded by the Robert Wood Johnson Foundation and managed by the Center for Health Care Strategies SCDHEC Oral Health Division 2006
  • 2. Contents
    • Section I: Pediatric Oral Health Overview
    • Section II: Professional Recommendations
    • Section III: Etiology and Prevention of Tooth Decay
    • Section IV: Anticipatory Guidance for Mother
    • Section V: Oral Health Risk Assessment—Young Children
    • Section VI: Anticipatory Guidance for Infants and Young Children
    • Section VII: Fluoride Varnish
    More Smiling Faces in a SCDHEC led oral health initiative funded by the Robert Wood Johnson Foundation and managed by the Center for Health Care Strategies
  • 3. Pediatric Oral Health Objectives
    • At the completion of this section, the
    • participant will be able to understand the:
      • Role of the medical professional in pediatric oral health promotion and the prevention of dental diseases
      • Recommendations for infant oral health of the American Academy of Pediatric Dentistry and the American Academy of Pediatrics.
      • Indications for the use of fluoride varnish as a preventive treatment for young children
      • Recommendations for oral health anticipatory guidance during pregnancy.
  • 4. Oral Health in America:
    • A Report of the Surgeon General
    • “… oral health is integral to general health (1)”
    Surgeon General David Satcher, MD, PhD and Lisa Waddell, MD, MPH, SCDHEC 2000
  • 5. A health problem: tooth decay One of the most common diseases of childhood 5 times as common as asthma 7 times as common as hay fever (1).
  • 6. Early childhood caries—tooth decay
    • Is defined as the presence of decayed primary teeth
    • Is also known as baby bottle tooth decay
    • Advances rapidly due to the thinness of the enamel
  • 7. What are the costs?
    • Children with early childhood tooth decay are more likely to get more decay in their permanent teeth.
    • Goes beyond pain and infection…
      • Affects their speech
      • Affects their ability to eat
      • Affects their ability to learn
      • Affects the way they feel about themselves
    • Dental treatment can be very costly, especially hospitalization for treatment.
  • 8. Why begin oral health with the medical provider?
    • First health professional to provide well child care to the infant and continues this care on a regular basis
    • Prevention is a critical component of pediatric care.
    • Today health professionals recognize the importance of oral health as part of total health
  • 9. American Academy of Pediatric Dentistry
    • Clinical Guideline on Infant Oral Health Care
      • Recognizes that allied health professionals and community organizations must be involved as partners to achieve a lifetime of freedom from preventable oral diseases.
    Lifetime of Freedom from Preventable Oral Disease Adult Oral Health Child and Adolescent Oral Health Infant Oral Health Birth to age 3- the foundation
  • 10. AAP and AAPD Recommendations
    • Oral risk assessment
      • including a visual oral screening
    • Anticipatory Guidance
    • Preventive strategies
    • Establishment of the dental home by age one
  • 11. Tooth Decay: how does it happen?
  • 12. Parent Sheet: The Bottle and Your Infant’s Dental Health Parent Information Booklet, page 9
  • 13. Tooth decay and infants
    • Oral flora colonize the mouth soon after birth
    • Current belief that cariogenic bacteria colonize only after the tooth erupt
    • Tooth decay can begin as soon as the teeth erupt at 6-10 months of age
  • 14. Tooth decay is an infectious, transmissible disease
    • Tooth decay bacteria is transmitted from mom or other primary caregiver to baby through
      • Fingers
      • Sharing eating utensils
      • Cleaning pacifier with mother’s saliva
    Parent Information Booklet: Your Infant Can Get Cavities From You, page 3 The Pacifier and Your Infant’s Dental Health, page 10
  • 15. Caries-risk assessment
    • Child’s History
      • History of dental decay in mother, child and other family members
      • Family is of low economic status
      • Child consumes a high sugar/complex carbohydrate diet
      • Child has special health care needs
      • Child was premature/low birth weight
      • Child routinely is prescribed medications that are sugar based or that reduce salivary flow
  • 16. Tools for a visual oral screening
    • Light
    • Tongue depressor
    • Long handled cotton swab/toothpick
    • 2x2 gauze
    • Toothbrush
  • 17. Knee to knee position
  • 18. Visual oral screening
    • Lift the lip
      • Check for presence of plaque and food on teeth
      • Check gums and soft tissues—look for abscesses
    Tip: a toothbrush can be used to count the child’s teeth and can also serve as a mouth prop, preventing the child from biting down on your finger.
  • 19. Examine the teeth
    • Observe the teeth from the
      • Outside surfaces
      • Look for “White Spots”
      • Look for obvious signs of tooth decay such as brown spots or breaks in the tooth surface
      • Look from the inside of the upper front teeth
  • 20. Looking at the back teeth
    • Look for
      • Dark spots and stains
      • Breaks in the tooth surface
  • 21. Show parent how to do a Smile Check
    • Gently lift your child’s upper lift
    • Look at the outside and the inside of the upper front teeth
    Parent Information Booklet: Smile Check, page 6
  • 22. Referral for dental care
    • The findings…are provided below:
      • Needs regular dental examination
      • Needs dental treatment within one month
      • Needs dental treatment immediately
  • 23. Needs regular dental examination
  • 24. Needs treatment within 1 month Special Note : an infant or child with any positive caries risk factors should be referred to a dentist within one month even though there are no observable dental problems.
  • 25. Immediate dental treatment
    • Signs or symptoms that include pain, infection, swelling or soft tissue ulceration of more than 2 weeks duration determined by questioning.
  • 26. Needs immediate treatment
  • 27. Establish a Dental Home
    • Refer high risk children by 6 months
    • Refer all children by the age of one
    Parent Information Booklet: How do I find a good dentist for my child?, page 14 Your Child’s First Dental Visit, page 15
  • 28. Children with Special Health Care Needs
    • Refer early referral for dental care (before or by age 1)
    • Collaboration with dentist is especially important
    • Emphasize with parents the importance of oral health to CSHCN
  • 29. Considerations for CSHCN
    • Medications for asthma and allergies often reduce salivary flow which increases risk for tooth decay
    • Children who are preterm or low birth weight have a higher rate of enamel defects and are at increased risk for tooth decay
    • Infants with feeding problems are often placed on special high carbohydrate diets
  • 30. Oral Hygiene
    • After feeding, an infant's teeth and gums shall be wiped with a moist cloth to remove any remaining liquid that coats the teeth and gums
    Parent Information Booklet How Can I Protect My Child’s Baby Teeth?, page 4
  • 31. Oral Hygiene: Infant to Toddler…
    • When teeth appear you can use a small, soft toothbrush
    Parent Information Booklet: Tips for Brushing Your Infant’s Teeth, page 8
  • 32. Oral Hygiene: Supervised Brushing Parent Information Booklet: How to Make Toothbrushing Fun! Page 23 How To Choose the Right Toothbrush and Toothpaste for Your Preschooler, page 24
  • 33. Diet and Oral Health
    • If the baby goes to bed with a bottle, only use water.
    • Baby should begin using a cup by 6 months
    • Wean from bottle to cup by age 1
    • Avoid letting baby walk around with a bottle or sippy cup with milk, juice or sweet liquid
    Parent Information Booklet: The Bottle and Your Infant’s Dental Health Sippy Cups, page 19
  • 34. Encourage Good Food Choices Parent Information Booklet: Healthy Eating Habits for Good Dental Health, page 16 Juice, page 17 Facts About Milk, page 18 Nutrition and Your Child’s Dental Health, page 30
  • 35. Medicines
    • Children’s medication often contain sugar
    • Some decrease the child’s salivary flow
    • Be sure to inform parents or caregivers to brush the child’s teeth after giving him or her their medication.
  • 36. Fluoride—the Tooth Protector
      • Water that may contains fluoride:
        • Community water systems
        • Well water with naturally occurring fluoride
      • Fluoride in the water helps slow down the loss of the tooth surface---by replacing the lost minerals with fluoride, a process called remineralization
      • Check local water systems for fluoridation information at:
        • CDC’s My Water’s Fluoride website: http://www.scdhec.net/hs/mch/dental/WaterFlou.html
        • Optimal fluoride concentration of water systems should be in the .7 to 1.2 parts per million
  • 37. ADA Recommended Supplements
  • 38. Fluoride Toothpaste
    • Small, pea sized amount beginning at age 2
    • Under age 2, water only
    • Supervised use under age 8 years
    Parent Information Booklet Toothbrushes and Toothpaste for Toddlers, page 12
  • 39. Injury Prevention
    • Parent Information Booklet:
      • Is Your Home Safe?, page 20
      • Safety: Toys and Dental Health, page 21
      • Home for the Holidays, page 22
      • Keeping Your Child’s Smile Safe When Riding in a Car, page 25
      • Keeping Your Child’s Smile Safe At Home and In School, page 26
      • Keeping Your Child’s Smile Safe When Shopping, page 27
      • How to Respond to a Dental Emergency, page 28
  • 40. Why do we recommend fluoride varnish for very young children?
    • To prevent dental caries and in some cases reverse early dental caries
    • Children with early childhood decay are more likely to get more decay
    • Baby teeth are in a child’s mouth until about age 11 or 12
  • 41. Who should receive fluoride varnish?
    • Children are at risk for developing dental caries.
    • Risk assessment based on the Caries Risk Assessment
  • 42. Risk factors for dental caries are:
    • History
      • History of dental decay in mother, child and other family members
      • Family is of low economic status
      • Child consumes a high sugar/complex carbohydrate diet
      • Child has special health care needs
      • Child was premature/low birth weight
      • Child routinely is prescribed medications that are sugar based or that reduce salivary flow
    • Clinical evaluation
      • Visible plaque, white spots and/or decay
      • Gingivitis—gums appear red, swollen, report bleeding when brushing
      • White spots/demineralization
  • 43. How does fluoride varnish work?
    • The lacquer-based product adheres to the dental enamel forming a depot from which fluoride is slowly released
    • A dry tooth surface allows the uptake of the fluoride into the tooth surface
    • Saliva actually sets the varnish
  • 44. Advantages of fluoride varnish
    • easy to apply
    • teeth do not need professional prophylaxis
    • children can eat and drink following applications
    • potential ingestion of fluoride is low due to the sticky form of the varnish and the small amount used
    • prevents tooth decay and reverses early decay
  • 45. White spots
  • 46. Knee to knee position
  • 47. Fluoride varnish application
    • 1. Dry teeth with gauze square
    • Apply varnish with brush to all teeth surfaces
  • 48. Post application instructions for parents
    • Varnish will set on contact with saliva and look like a yellowish film
    • Child can eat or drink right after application but should try to eat soft foods
    • Instruct parent not to brush their child’s teeth until the next day.
    • The first toothbrushing will remove the yellow film on the teeth.
  • 49. Three months later Remineralized Enamel
  • 50. You can make a difference!!
    • Integrate oral health assessment into well child visits
    • Provide patient education regarding oral health
    • Document findings and follow up
    • Train office staff in oral assessment
    • Identify dentists in your area who accept new patients and Medicaid patients.
    • Take a dentist to lunch to establish a referral relationship
    • Investigate fluoride content in area water supply
  • 51. Anticipatory Guidance for Mother
    • At the completion of this section, the participant will be able to describe anticipatory guidance for the mother both before the baby is born and following the infant’s birth.
  • 52. Water
    • Ask your doctor or your dentist if your water has fluoride in it.
    • Fluoride is a safe, easy way to protect your teeth from tooth decay.
    • If you buy bottled water, check the label for fluoride.
  • 53. Anticipatory guidance for mother
    • Or other intimate caregiver before and during colonization process
      • Brush and floss daily to disturb cariogenic bacteria and reduce bacterial plaque levels
      • Use toothpaste with fluoride
  • 54. Eat healthy foods
    • Chose foods low in sugar.
    • Eat healthy snacks like fruit, cheese and vegetables.
    • Get enough calcium for you and your baby’s healthy teeth and bones.
    • Calcium is in milk, cheese, dried beans and leafy green vegetables.
    • Avoid carbonated drinks
  • 55. Dental care for mother
    • Refer to dentist to:
      • To maintain or to restore to health the oral tissues which includes not only healthy teeth but also gums and the supporting tissues or the oral cavity.
      • If dental caries are present, removal of decay and restoration of teeth
  • 56. Mother chewing xylitol gum
    • Recent evidence suggests that chewing xylitol gum kills cariogenic bacteria
    • Chew
      • 1 piece of gum
      • for 5 minutes
      • 3-5 times a day
    • decreases the child’s caries rate.
  • 57. Now is the time for mom to learn
    • How to keep her child cavity-free!
    • Get her mouth healthy—see her dentist
    • Learn how to do a Smile Check on a baby
    • Learn how to clean a baby’s teeth
    • Learn how to prevent baby bottle tooth decay by not putting the baby in bed with a bottle at night or naptime.
    • Be prepared to ask her doctor or dentist to check you’re the baby’s teeth by age one.
    • Talk to her doctor or dentist about fluoride.