Oral-Health



“Oral health is an essential and integral component of health throughout life. No one can be truly healthy unless he or she is free from the burden of oral and craniofacial diseases and conditions.” - Excerpt from the report //Healthy People 2010: Oral Health//.

**FACILITATORS: Brooke Marshall, Laura Uhlmansiek**


 * **Contents** * Learner Objectives
 * Required Readings and Websites
 * Healthy People 2020 Objective
 * Related Epidemiological Data
 * Screening Guidelines and Assessment Parameters
 * Behavioral Intervention Recommendations
 * Discussion of Intervention Efficacy ||

= Learner Objectives » =


 * ====Analyze how the oral health of children and adolescents impacts Healthy People 2020 goals and objectives.====
 * ====Identify risk factors associated with poor dental health of children and adolescents.====
 * ====Identify and explain what particular family levels of care would be appropriate to promote oral health, and incorporate coordinating interventions.====
 * ====Use appropriate USPSTF screening and immunization recommendations to promote oral health of children and adolescents.====

 Required Readings and Websites

 * McDaniel, S. H., Campbell, T., Hepworth, J., & Lorenz, L. //Family oriented primary care (2nd ed).// New York, NY: Springer.
 * **Chapter 11.** Supporting parents: Family-oriented child healthcare
 * [|Jackson, S. L., F., Kotch, J. B., Pahel, B. T., & Lee, J. Y. (2011). Impact of Poor Oral Health on Children's School Attendance and Performance. American Journal Of Public Health, 101(10), 1900-1906. doi:10.2105/AJPH.2010.200915]
 * [|Marrs, J., Trumbley, S., & Malik, G. (2011). Early Childhood Caries: Determining the Risk Factors And Assessing the Prevention Strategies For Nursing Intervention. Pediatric Nursing, 37(1), 9-15.]
 * [|DiMarco, M.A, Huff, M., Kinion, E., & Kendra, M.A. (2009). The Pediatric Nurse Practitioner's Role in Reducing Oral Health Disparities in Homeless Children. Journal of Pediatric Health Care. 23(7), 109-116]
 * [|WEBSITE: Healthy People 2020 Oral Health]
 * ====[|WEBSITE: CDC Children's Oral Health]====
 * [|WEBSITE: USPSTF to identify appropriate prevention interventions]
 * media type="youtube" key="qXiZJIaIwnc" height="315" width="560"

**Recommended Readings and Websites**

 * [|Task Force on Community Preventative Services. (2002). Recommendations on selected interventions to prevent dental caries, oral and pharyngeal cancers, and sports-related craniofacial injuries. Am J Prev Med, 23, 16-20.]
 * [|CDC. (2011). Preventing Cavities, Gum Disease, Tooth Loss, and Oral Cancers, At A Glance 2011]
 * [|Vidal, L. & Gillison, M.L. (2008). Human papallomavirus in HNSCC: Recognition of a distinct disease type. Hematology/Oncology Clinics of North America 22(6), 1125-1145.]This article discusses currrent data that supports the HPV infection is responsible for certain head and neck squamous cell carcinomas (HNSCC), not due to alcohol or tobacco. Patients who are positive for HPV HNSCC have better outcomes than those negative for HPV HNSCC. Additionally, those who are HPV HNSCC positive have different clinical presentations than those negative for HPV HNSCC.

Healthy People 2020 objectives related to children and adolescent oral health include:

 * ====Reduce the proportion of children and adolescents who have dental caries experience in their primary or permanent teeth====
 * ====Reduce the proportion of children and adolescents with untreated dental decay====
 * ====Increase the proportion of school-based health centers with an oral health component====

** Gender is Not a Significant Factor **
==== Tooth decay affects males and females alike. Data shows no significant findings between males and females in regards to the prevalence of dental caries. From 2001 to 2004, 20% of males ages 2-5 years old and 19.1% of females ages 2-5 were reported to have untreated dental caries. Similar results were found in the 6-19 year old age group with males at 23.9% and females at 22% (CDC, 2004). These statistics display that gender does not play a significant role in the development of dental caries. ====

** Racial and Ethnic Disparities DO Exist **
==== As displayed by the chart below, from 2001-2004 African Americans (24.2%) and Hispanic children of Mexican origin (29.2%) had significantly higher percentages of untreated cavities than white, non-Hispanic children (14.5%) (CDC, 2004). This is a significant finding with Hispanic children of Mexican origin having the highest percentage of untreated dental caries when compared to non Hispanic Whites and African Americans. ====

** Percent of Poverty Level is a Significant Factor **
==== In 2001-2004, 26% of 2-5 year olds and 31% of 6-19 year olds below 100% of the poverty level had untreated cavities. While 25.4% of 2-5 year olds and 32.7% of 6-19 year olds between 100% but less than 200% of the poverty level had untreated cavities. In contrast, only 12.1% of 2-5 year olds and 14% of 16-19 year olds at 200% or more above the poverty level had untreated dental caries (CDC, 2004). These statics show that there is a strong correlation between socio economic status and untreated dental caries. ====



**USPSTF Screening recommendations related to oral health includes the following:**
> ====//**Rationale:** The USPSTF found fair evidence that, in preschool children with low fluoride exposure, prescription of oral fluoride supplements by primary care clinicians leads to reduced dental caries.//====
 * ====The USPSTF recommends primary care physicians providing oral fluoride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source is deficient in fluoride. ***Grade B Recommendation**====


 * ====The USPSTF concludes that the evidence is insufficient to recommend for or against routine risk assessment of preschool children by primary care clinicians for the prevention of dental disease. ***Grade I Recommendation**====


 * ====The USPSTF concludes that the evidence is insufficient to recommend for or against routinely screening adults for oral cancer. ***Grade I Recommendation**====

National Guideline Clearinghouse (2010) recommendations for children and adolescents related to oral health include:

 * ====Fluoride should be recommended to prevent caries and cavities.====
 * ====Risk assessment including oral screening and referral for dental care should be recommended for those at high risk.====
 * ====Counseling on oral health preventive measures should be recommended.====
 * ====Refer to the original guideline document for information on efficacy of oral health counseling and treatment.====


 * Education should include:**

Birth-2 years

 * ====Do not use fluoridated toothpaste under one year of age.====
 * ====Use fluoride varnish for patients at high risk of cavities if mechanisms to successfully and consistently deliver this in the clinic setting are available. Access Web-based or in-person training to acquire knowledge and skills.====
 * ====Discourage the practice of putting infants and children to bed with a bottle.====
 * ====Encourage women to breastfeed.====
 * ====Encourage healthy eating habits to reduce the risk of dental caries. In particular, avoidance of frequent sugar intake.====
 * ====Encourage regular dental visits. Children at high risk for dental caries should be referred to the appropriate dental provider.====

2-18 years

 * ====Parents should be advised to have children brush teeth daily with toothpaste containing 1,000 to 1,500 ppm of fluoride. Use a pea-sized amount of fluoride toothpaste for children over two years of age.====
 * ====Consider fluoride varnish for patients at high risk of cavities if mechanisms to successfully and consistently deliver this in the clinic setting are available.====
 * ====Provide daily fluoride supplements of 1 mg of fluoride for those patients over six years of age who do not have fluoride in their water supply already.====
 * ====Encourage regular dental visits.====
 * ====Consider daily flossing.====
 * ====Children at high risk for dental caries should be referred to the appropriate health care source.====
 * ====Encourage healthy eating habits to reduce the risk of dental caries. In particular, avoidance of frequent sugar intake.====
 * //Based on a Level II recommendation, in which providers should assess the need for and recommend these services to every patient.//
 * [|Click here for parental educational brochures]

National Guideline Clearinghouse Recommendations for Timing of Pediatric Oral Health Services (2007)

 * 1) =====First examination at the eruption of the first tooth and no later than 12 months. Repeat every 6 months or as indicated by child's risk status/susceptibility to disease. Includes assessment of pathology and injuries.=====
 * 2) =====By clinical examination.=====
 * 3) =====Must be repeated regularly and frequently to maximize effectiveness.=====
 * 4) =====Timing, selection, and frequency determined by child's history, clinical findings, and susceptibility to oral disease.=====
 * 5) =====Consider when systemic fluoride exposure is below the optimal level. Up to at least 16 years.=====
 * 6) =====Appropriate discussion and counseling should be an integral part of each visit for care.=====
 * 7) =====Initially, responsibility of parent; as child matures, jointly with parent; then, when indicated, only child.=====
 * 8) =====At every appointment; initially discuss appropriate feeding practices, then the role of refined carbohydrates and frequency of snacking in caries development and childhood obesity.=====
 * 9) =====Initially play objects, pacifiers, car seats; then when learning to walk, sports and routine playing, including the importance of mouthguards.=====
 * 10) =====At first discuss the need for additional sucking: digits vs. pacifiers; then the need to wean from the habit before malocclusion or skeletal dysplasia occurs. For school-aged children and adolescent patients, counsel regarding any existing habits such as fingernail biting, clenching, or bruxism.=====
 * 11) =====For caries-susceptible primary molars, permanent molars, premolars, and anterior teeth with deep pits and fissures; placed as soon as possible after eruption.=====

Oral health risk factors to assess include (CDC, 2011):

 * Tobacco use
 * Excessive alcohol use
 * Poor dietary choices
 * Limited access to and availability of dental services
 * <span style="font-family: 'Arial','sans-serif'; font-size: 14px;">Lack of awareness of the need for care
 * <span style="font-family: 'Arial','sans-serif'; font-size: 14px;">Cost
 * <span style="font-family: 'Arial','sans-serif'; font-size: 14px;">Fear of dental procedures

Open Wide - Oral Health Training for Health Professionals (2010)
====Health care providers see infants and children frequently, therefore they must be able to help prevent and reduce the risk of tooth decay, as well as provide appropriate referrals. Open Wide is oral health training for health professionals, and includes performing an oral health risk assessment, providing the appropriate referrals, and anticipatory guidance to family members. The following is the oral health risk assessment tool that health care providers can use:====




 * **2 - Recommended (A, B)** ||
 * Grade || Title || Risk Info. || Details ||
 * **[|B]** || **Dental Caries**: Oral Fluoride Supplementation -- Preschool Children 6 Months and Older || [[image:http://epss.ahrq.gov/ePSS/images/group.gif caption="View Risk information" link="http://epss.ahrq.gov/ePSS/GetResults.do?method=search#"]] || [[image:http://epss.ahrq.gov/ePSS/images/detailview.gif caption="View Recommendation Details" link="http://epss.ahrq.gov/ePSS/RecomDetail.do?sid=47&age=3&sex=Male&sexuallyActive=no&tobacco=no"]] ||
 * **[|B*]** || **Visual Impairment**: Screening -- All children at least once between ages of 3 and 5 years ||

Recommended for all ages 6 months – 6 years (if no contraindications identified)

 * ====Hepatitis B at birth, 1-2 months and 6-18 months====
 * ====RV at 2 months, 4 months and 6 months====
 * ====DTap at 2 months, 4 months, 6 months, 15-18 months, and 4-6 years====
 * ====HIB at 2 months, 4 months, 6 months and 12-15 months====
 * ====PCV at 2 months, 4 months, 6 months and 12-15 months====
 * ====IPV at 2 months, 4 months, 6-18 months and 4-6 years====
 * ====Influenza (yearly)====
 * ====MMR at 12-15 months and 4-6 years====
 * ====Varicella at 12-15 months and 4-6 years====
 * ====Hepatitis A at 12-23 months====



Recommended for all ages 7 – 18 years of age (if no contraindications identified)

 * ====Tdap at 11-12 years of age====
 * ====HPV at 11-12 years of age (3 doses)====
 * ====Meningococcal conjugate vaccination at 11-12 years and booster at 13-18 years====

Those, ages 7 – 18 years, with certain health conditions that put them at high risk for serious disease should also receive:

 * ====Pneumococcal vaccination between 7-18 years (one dose)====
 * ====Hepatitis A vaccine series between 7-18 years====



The CDC (2011) recommends the following interventions to promote oral health:

 * ====Encourage children to eat regular nutritious meals and avoid frequent between-meal snacking.====
 * ====Protect your child's teeth with fluoride.Talk to your child's dentist about dental sealants because they protect teeth from decay.====
 * ====Use a fluoride toothpaste. If your child is less than 7 years old, use only a pea-sized amount.====
 * ====If your drinking water is not fluroridated, talk to a dentist or physician about the best way to protect your child's teeth====
 * ====If you are pregnant, get prenatal care and eat a healthy diet. The diet should include folic acid to prevent birth defects of the brain and spinal cord and possibly cleft lip/palate====

The US Department of Health and Human Services (2012) Recommends:

 * ====**Start with the first tooth.** Once your baby’s teeth come in, clean them with a soft children’s toothbrush, especially right before bedtime.====
 * ====**Teach your child to brush 2 times a day.** Kids can brush their own teeth around age 4-5. Observe your kids while brushing and remind them not to swallow the toothpaste.====
 * ====**Make it fun.** Let your kid choose their own fun toothbrush, and give them a sticker after each brushing.====
 * ====**//Avoid sweet drinks between meals.//** Give your kids water instead of sweet drinks between meals. Reminder: milk, formula, and juice all have sugar in them.====
 * ====**//Don’t put your baby to bed with a bottle.//** Milk or formula will stay on your child’s teeth all night and increase your child’s risk for tooth decay.====
 * ====**Take your child to the dentist.**Take your child to the dentist for a checkup by age 1, and at least once every year after that.====

Community Interventions (Task Force of Community Preventative Services, 2002)
====Community water fluoridation involves adding a controlled amount of fluoride to public water supply in order to maintain an optimal level of fluoride. There is strong evidence that by adding fluoride to the water reduces tooth decay. Based on 21 studies reviewed, there was a 21.9% decrease in decay rates measured before and after water fluoridation in those 4-17 years old (Task Force of Community Preventative Services, 2002). Decay rates decreased in those with varying risk factors, including those of varying tooth decay rates, sosioeconomic status, and race.====



School-Based Dental Sealant Programs (Task Force on Community Preventative Services, 2002)
====There is strong evidence that school-based and school-linked dental sealant delivery programs prevent and reduce the incidence of tooth decay. These programs provide pit and fissure sealants to those who would unlikely receive them otherwise. School-based programs are conducted in the school setting; where as school-linked programs take place in the school and/or clinic settings. Many of these programs target high risk children who are at high risk for developing dental caries. High risk children are those that come from a vulnerable population, and receive a reduced or free lunch. Additionally, these programs target the children who would not have otherwise had resources to these services. Based on 10 studies reviewed which compared children in sealant programs and those not in a sealant program, there was a 60% decrease in dental caries in children 6-17 years old (Task Force on Community Preventive Services, 2002).====

Water Fluoridation Program
====There is strong evidence that supports the water fluoridation program and it's role in prevention and reduction of tooth decay. Water fluoridation programs also have the potential to reduce disparities in tooth decay and dental caries among all socioeconomic groups, races and communities (Task Force on Community Preventive Services, 2002). The Task Force also mentions a "halo" effect, in which fluoridated products can benefit those of non-fluoridated water communities. For example, beverages made from fluoridated water can branch to surrounding communities, providing those individuals with benefits of fluoridation, too (Task Force on Community Preventive Services, 2002).====

**School-Based Sealant Programs**
====The evidence demonstrates that school-based sealant programs work to stop and prevent tooth decay. In 2003, the Association of State and Territorial Dental Directors published a Best Practice Approach Report which provides scientific evidence that school sealant programs are beneficial (Task Force on Community Preventive Services, 2002). School-based programs have the potential to lead to more outside support for both dental and non-dental needs of low-income families (Task Force Community Preventative Services, 2002).====

<span style="color: #000099; font-family: Verdana,Geneva,sans-serif;">D2L Discussion Prompt »
====I am Ms. Gomez. I am Hispanic, 28 years old, and this is Pedro, my 3 year old child. People tell me Pedro is too big and that he should see a dentist. But I think he is healthy and I don’t have enough money to buy our food, and cannot afford a dentist. We live in an urban area and our home was built in the 1950s. We barely have enough money to make ends meet. I can’t afford fresh fruits, so Pedro mostly snacks on cookies and candy.====

**Discussion prompt**
====How can you increase Ms. Gomez’s access to dental care and oral health prevention services? Review the family levels of care (e.g., minimal, information & collaboration, feeling & support, primary care family assessment & counseling, and medical family therapy) in Mc Daniel, et al. (2005) Chapter 1.====

(e) Identify 2 other screening or clinical prevention strategies that are appropriate for Pedro today.
= References = Centers for Disease Control and Prevention. (2011). Children’s oral health. Retrieved from: []

Center for Disease Control and Prevention. (2004). Untreated Dental Caries in Children Ages 2-19, United States. Retrieved from: []

[|DiMarco, M.A, Huff, M., Kinion, E., & Kendra, M.A. (2009). The Pediatric Nurse Practitioner's Role in Reducing Oral Health Disparities in Homeless Children. Journal of Pediatric Health Care. 23(7), 109-116]

Healthy People 2020. (2012). Oral Health. Retrieved from: []

Jackson, S. L., F., Kotch, J. B., Pahel, B. T., & Lee, J. Y. (2011). Impact of Poor Oral Health on Children's School Attendance and Performance. American Journal Of Public Health, 101(10), 1900-1906. doi:10.2105/AJPH.2010.200915

Marrs, J., Trumbley, S., & Malik, G. (2011). Early Childhood Caries: Determining the Risk Factors And Assessing the Prevention Strategies For Nursing Intervention. Pediatric Nursing, 37(1), 9-15.

McDaniel, S. H., Campbell, T., Hepworth, J., & Lorenz, L. Family oriented primary care (2nd ed). New York, NY: Springer. Task Force on Community Preventative Services. (2002). Recommendations on selected interventions to prevent dental caries, oral and pharyngeal cancers, and sports-related craniofacial injuries. Am J Prev Med, 23, 16-20.

National Guideline Clearinghouse. (2010). Preventative services for children and adolescents. Retrieved from: []

National Guideline Clearinghouse. (2007). Guideline on periodicity of examination, preventitive dental services, anticipatory guidance/counseling, and oral treatment for infants, children and adolescents. Retrieved from: []

US Community Preventative Services Task Force. (2012). Oral health. Retireved from: []

US Department of Health and Human Services. (2012). Take care of your child's teeth: Take action. Retrieved from: []

United States Preventive Services Task Force (2009). Retrieved from []

[|Vidal, L. & Gillison, M.L. (2008). Human papallomavirus in HNSCC: Recognition of a distinct disease type. Hematology/Oncology Clinics of North America 22(6), 1125-1145.]