ESTABLISHMENT OF A DENTAL HOME FOR PEDIATRIC DENTAL

ESTABLISHMENT OF A DENTAL HOME FOR PEDIATRIC DENTAL PATIENTS Dr. Lisa Jacob Chief of Pediatric Dental Medicine Dell Children’s Medical Center Austin, TX

Early Detection __ Infants be evaluated by a dentist within 6 months of eruption of their first tooth and no later than 12 months __ Allows a dentist to assess a child’s risk of developing caries __ Counsel parents and caregivers about what they can do to reduce risk © Lisa S Jacob, DDS, MS 2009

Goal Establish an ongoing relationship between dentist and the patient, inclusive of all aspects of oral health care, delivered in a comprehensive continuously accessible, coordinated and family centered way © Lisa S Jacob, DDS, MS 2009

Dental Home D 0145 - Oral evaluation for a patient under three years of age and counseling with primary caregiver Goal: To prevent dental problems © Lisa S Jacob, DDS, MS 2009

First Dental Home Visit 1. Review of Dental and Medical history 2. Comprehensive oral examination 3. Caries risk assessment 4. Application of topical fluoride varnish 5. Dental prophylaxis 6. Oral hygiene instructions with primary caregiver 7. Dental anticipatory guidance 8. Establishment of recall schedule © Lisa S Jacob, DDS, MS 2009

Why complete a caries risk assessment? Determine potential for development of Severe Early Childhood Caries by identifying: √ Oral Health Status √ Potential transmission sources Direct dental anticipatory guidance content Determine an appropriate recall periodicity schedule for the child © Lisa S Jacob, DDS, MS 2009

Caries Risk Assessment Tool (CAT) 2002 - American Academy of Pediatric Dentistry (AAPD) adopted CAT for infants, children, and adolescents 2006 AAPD revised the CAT AAPD encouraged both dental and non-dental health care providers to use the CAT Clinicians had to perform an adequate visual examination of the child’s teeth and mouth © Lisa S Jacob, DDS, MS 2009

Risk factors to consider History Determined by interviewing the parent/primary caregiver Clinical evaluation Determined by examining the child’s mouth Supplemental Professional Assessment Optional © Lisa S Jacob, DDS, MS 2009

High caries risk patient Each child’s overall assessed risk for developing decay is based on the highest level of risk indicator Single risk in any area of the “high risk” category classifies a child as being “high risk” © Lisa S Jacob, DDS, MS 2009

Child’s use of dental home Frequency of dental visits Never : High risk Irregular: Moderate risk Regular: Low risk http: //www. ardentoys. co. uk/images/uploads/bay-tree-house 2. jpg © Lisa S Jacob, DDS, MS 2009

Child has decay Yes: High risk No: Low risk www 1. istockphoto. com/file_thumbview_approve/1609464/2/istockphoto_1609464_uh_oh_a_cavity_vector. jpg © Lisa S Jacob, DDS, MS 2009

Patients with special needs Especially those that impact motor coordination or cooperation Ectodermal dysplasia Dental enamel is not well mineralized n Newbrun E. Current treatment modalities of oral problems of patients with Sjogren’s syndrome: caries prevention. Adv Dent Res. 1996: 10; 20 -34. © Lisa S Jacob, DDS, MS 2009

Parent’s socioeconomic status Low SES: High risk Midlevel SES: Moderate risk High SES: Low risk © Lisa S Jacob, DDS, MS 2009 http: //library. thinkquest. org/J 003358 F/money_tree 5. jpg

Impaired saliva composition/flow n Long-term doses of medications can increase caries risk Impaired salivation High mineral loss n Bardow A, Nyvad B, Nauntofte B. Relationships between medication intake and complaints of dry mouth, salivary flow rate and composition, and the rate of tooth demineralization in situ. Arch Oral Biol. 2001: 46; 412 -23. © Lisa S Jacob, DDS, MS 2009

Time lapsed since child’s last cavity <12 months: High risk 12 -24 months: Moderate risk >24 months: Low risk http: //www. ntlf. com/images/calendar. jpg © Lisa S Jacob, DDS, MS 2009

Child wears braces or orthodontic/oral appliances Yes: High risk No: Low risk © Lisa S Jacob, DDS, MS 2009

Child’s immediate family has decay Yes: High risk No: Low risk The earlier the child is infected… the higher the risk of caries Vertical transmission ↓ Mother to child Horizontal transmission ↔ Sibling to sibling © Lisa S Jacob, DDS, MS 2009

Daily intakes Between-Meals and cavity producing foods Mealtimes: Low risk 1 -2 snacks: Moderate risk >3 snacks: High risk Consumption of juice, carbonated beverages or sports drinks Use of bottle/sippy cup containing liquid other than water Use of sweetened medications © Lisa S Jacob, DDS, MS 2009

Child’s exposure to fluoride High Risk n n n Does not use fluoridated toothpaste Drinking water is not fluoridated Does not take fluoride supplements Moderate Risk n n n Uses fluoridated toothpaste Usually does not drink fluoridated water Does not take fluoride supplements Low Risk n n n Uses fluoridated toothpaste Drinks fluoridated water Takes fluoride supplements © Lisa S Jacob, DDS, MS 2009

Times per day that the child’s teeth/gums are brushed n n n <1: High risk 1: Moderate risk 2 -3: Low risk http: //www. eslkidstuff. com/images/toothbrush. gif © Lisa S Jacob, DDS, MS 2009

Clinical Evaluation © Lisa S Jacob, DDS, MS 2009

Visible Plaque Present: High risk Absent: Low risk n http: //www. scharfphoto. com/fine_art_prints/archives/199901 -024 -Dental-Plaque. jpg © Lisa S Jacob, DDS, MS 2009

Gingivitis Present: High risk Absent: Low risk © Lisa S Jacob, DDS, MS 2009

Areas of enamel demineralization >1: High risk 1: Moderate risk None: Low risk n http: //www. uiowa. edu/~c 090247/images/varnish/demineralized. jpg © Lisa S Jacob, DDS, MS 2009

Enamel Defects Deep pits/fissures Present: High risk Absent: Low risk n http: //www. ojrd. com/content/figures/1750 -1172 -2 -171. jpg © Lisa S Jacob, DDS, MS 2009

Tooth anatomy and hypoplastic defects Developmental pits and deep pits have been shown to predispose a child to develop dental caries © Lisa S Jacob, DDS, MS 2009

Radiographic Enamel Caries Present: High risk Absent: Low risk n http: //www. ndeb. ca/en/accredited/images/SNAG-0202. jpg © Lisa S Jacob, DDS, MS 2009

Levels of mutans streptococci or Lactobacilli High: High risk Moderate: Moderate risk Low: Low risk © Lisa S Jacob, DDS, MS 2009

Dental Record Document Caries Risk ▲ High ► Moderate ▼ Low © Lisa S Jacob, DDS, MS 2009

Topical Fluoride Varnish D 1206 * Therapeutic application for moderate to high caries risk patients * Goal is to eliminate or control a disease * Prevent and re-mineralize early caries © Lisa S Jacob, DDS, MS 2009

Fluoride Varnish Advantages High dose with minimal volume Minimal swallowing Contact on teeth for hours Reduced caries Low plasma fluoride levels Tolerated by children Unit dose Fast © Lisa S Jacob, DDS, MS 2009

Fluoride Varnish 5% NAF Disadvantages Fuzzy, sticky and uneven Appearance on tooth 4 -6 hours you can’t brush Soft food for one day © Lisa S Jacob, DDS, MS 2009

Topical Fluoride Inhibits demineralization Enhances re-mineralization Inhibits plaque bacteria © Lisa S Jacob, DDS, MS 2009

Topical application of fluoride D 1203 (Child) Foams Gels n Most effective if placed in mouth for four minutes © Lisa S Jacob, DDS, MS 2009

Fluoride testing Fluori-check (Omnii Oral) © Lisa S Jacob, DDS, MS 2009

Fluoride Products © Lisa S Jacob, DDS, MS 2009

Oral Hygiene Instructions D 1330 Toothbrushing Flossing © Lisa S Jacob, DDS, MS 2009

Toothbrushes Electric toothbrush Spin Brush © Lisa S Jacob, DDS, MS 2009

Surround Toothbrush _ 3 rows of bristles _ Compact head _ Helps protect the oral environment if the person moves unexpectedly during brushing © Lisa S Jacob, DDS, MS 2009

Flossers © Lisa S Jacob, DDS, MS 2009

Nutritional counseling for control of dental disease D 1310 * Frequency of intake is more important than overall quantity * “Grazing” between meals should be discouraged * Avoid frequent consumption of sodas * Sweet intake should be limited-mealtime © Lisa S Jacob, DDS, MS 2009

Bacterial Cultures Identify the presence of cariogenic bacterial infections © Lisa S Jacob, DDS, MS 2009

Caries Susceptibility Test D 0425 If mother has had active dental decay in the past 12 months, dentist may perform a bacterial culture on the mother If primary caregiver’s bacteria count is significant, the dentist will develop prevention strategy Minimizes the risk of mom transmitting the infection to the child © Lisa S Jacob, DDS, MS 2009

Recommendations for caregiver √ Antibacterial rinse √ Chew xylitol gum or mints each day Studies show that chewing xylitol gum 4 times a day helps reduce the transmission of cariogenic bacteria from caregivers to infants © Lisa S Jacob, DDS, MS 2009

Dental anticipatory Guidance * Age appropriate information/education for parents * Multi-topic overview of oral health environmental influences * Directed at increasing the parents understanding of the importance of good health © Lisa S Jacob, DDS, MS 2009

Dental anticipatory Guidance * Discuss oral health and home care * Development of Mouth and Teeth * Oral Habits * Diet, Nutrition and Food Choices * Fluoride Needs * Injury Prevention * Antimicrobials © Lisa S Jacob, DDS, MS 2009

Birth -1 year old √ Clean baby’s mouth/brush teeth √ Parents need to maintain their own oral health √ Do not share utensils and cups √ Discuss primary tooth eruption patterns √ Discuss teething and ways to sooth sore gums © Lisa S Jacob, DDS, MS 2009

Birth-1 year old √ Review pacifier use √ Do not put baby to bed with bottle √ Encourage use of cup by year one √ Fluoride needs √ Child proof the home √ Car seat usage √ Discuss use of medications with sweeteners © Lisa S Jacob, DDS, MS 2009

1 -3 years old ☺ Offer healthy food, snacks, drinks ☺ Clean baby’s teeth ☺ Use fluoridated toothpaste (smear) ☺ Continue regular dental visits ☺ Discuss importance of baby teeth with parents ☺ Begin weaning of non-nutritive sucking habits by age 2 © Lisa S Jacob, DDS, MS 2009

1 -3 years old ☺ Continue Healthy nutritional choices ☺ Frequency of exposures Do not use sippy cup like a bottle No running with objects in mouth Helmet use with toddlers riding bikes © Lisa S Jacob, DDS, MS 2009

3 -5 years old * Pea-sized amount of fluoridated toothpaste * Discuss permanent tooth eruption patterns * Importance of teeth * Discuss consequences of digit sucking or prolonged non nutritive sucking * Should be using a regular cup © Lisa S Jacob, DDS, MS 2009

Behavior Guidance * “a clinical art form and skill built on a foundation of science” * Continuum of interaction involving the dentist, dental team, the parent, and the patient © Lisa S Jacob, DDS, MS 2009

Goals √ √ Establish communication √ Promote child’s positive attitude toward dental health Alleviate fear and anxiety Deliver quality dental care Build a trusting relationship between dentist and child © Lisa S Jacob, DDS, MS 2009

Dental Office Website __ Introduce parents to the practice Location __ FQHC dental within medical clinic Design __ Kid friendly © Lisa S Jacob, DDS, MS 2009

DENTAL TEAM BEHAVIOR Receptionist __ First contact with parent via phone __ Sets expectations __ First staff member the child meets Dental Assistant __ Language Dental Hygienist __ Establish rapport Dentist __ “White Coat Syndrome” © Lisa S Jacob, DDS, MS 2009

Recommend behavior guidance based on: * Health history * Consequences of no treatment * Special health needs * Dental Needs * Type of treatment required * Emotional and intellectual development of patient * Parental preferences © Lisa S Jacob, DDS, MS 2009

BASIC BEHAVIOR GUIDANCE © Lisa S Jacob, DDS, MS 2009

VOICE CONTROL Gain the patient’ attention Establish adult-child roles Controlled alteration of : Voice Volume Pace Tone © Lisa S Jacob, DDS, MS 2009

Non-verbal Communication Reinforcement and guidance of behavior through: Appropriate contact Posture Body Language Facial Expression Gain or maintain the patient’s attention © Lisa S Jacob, DDS, MS 2009

TELL-SHOW-DO Tailored verbal explanation of procedures Educate – importance of dental visit Familiarize patient with dental setting Demonstrate: It’s OK to Visual, Auditory, Touch, Taste, Smell © Lisa S Jacob, DDS, MS 2009

POSITIVE REINFORCEMENT Rewarding desired behavior ☺ ☺ ☺ Verbal praise Prizes Facial expression Gives appropriate feedback Strengthens recurrence of those behaviors © Lisa S Jacob, DDS, MS 2009

DISTRACTION Diverting the patient’s attention from what may be perceived as an unpleasant procedure ≈ Find out interests ≈ Give patient a short break © Lisa S Jacob, DDS, MS 2009

PARENTAL PRESENCE/ABSENCE __ Gain patient’s attention __ Improve compliance __ Depends on if the parent can help reduce the patient’s anxiety __ Parental attitudes have changed __ Legal reasons __ Do not use with parents who are unwilling or unable to extend effective support © Lisa S Jacob, DDS, MS 2009

MODELING Have a patient observe the positive behavior of another patient © Lisa S Jacob, DDS, MS 2009

HYPNOSIS Guided self-imagery that focuses in relaxation and analgesia * Helps decrease gagging * Helps overcome dental phobia © Lisa S Jacob, DDS, MS 2009

ADVANCE BEHAVIOR GUIDANCE → Protective Stabilization → Nitrous oxide → Conscious Sedation → General anesthesia © Lisa S Jacob, DDS, MS 2009

PROTECTIVE STABILIZATION * Any form of restriction of movement by a patient in the dental environment * Reduce or eliminate untoward patient movement * Protect patient, staff, dentist or parent from injury * Facilitate delivery of quality dental care © Lisa S Jacob, DDS, MS 2009

INDICATIONS Patient requires immediate diagnosis or limited treatment Use with sedated patient that need to help reduce untoward movement © Lisa S Jacob, DDS, MS 2009

PHYSICAL RESTRAINS Head holds Hand guarding Used by dental assistant Therapeutic holds Third person © Lisa S Jacob, DDS, MS 2009

Dental Record for any use of Stabilization Informed consent Indication Type Duration of application Frequency of stabilization evaluation and safety adjustments Behavior evaluation/rating during stabilization © Lisa S Jacob, DDS, MS 2009

Precautions with protective stabilization √ Tightness and duration must be monitored √ Do not restrict breathing and circulation √ Must not use if patient experiences severe stress or hysteria © Lisa S Jacob, DDS, MS 2009

MOUTH PROPS Mc. Kesson Bite Block Molt © Lisa S Jacob, DDS, MS 2009

Mouth Rest Open Wide Mouth Rest. Disposable Reusable Can hold a saliva ejector in

Positioning Devices ☺ Wheelchair head supports ☺ Bean Bags ☺ Rainbow Airway Positioner ©

Stay N Place Booster Chair © Lisa S Jacob, DDS, MS 2009

Rainbow Elbow and Knee Stabilizers Easy to apply and remove “Incremental Relaxation” teaching tool for patients to learn safe behavior © Lisa S Jacob, DDS, MS 2009

NITROUS OXIDE Safe and effective technique to Reduce anxiety Enhance effective communication Rapid onset of action Easily titrated and reversible Rapid recovery Helps with: analgesia, amnesia and gag reflex reduction © Lisa S Jacob, DDS, MS 2009

CONSCIOUS SEDATION √ Control anxiety √ Minimize psychological trauma √ Maximize potential of amnesia √ Control behavior movement © Lisa S Jacob, DDS, MS 2009

DENTAL RECORD * Informed consent * Instructions and information * Medical evaluation * Time based record monitoring patient HR, BP, RR, Oxygen saturation * Adverse events * Time and condition of patient at discharge © Lisa S Jacob, DDS, MS 2009

General Anesthesia * Controlled state of unconsciousness accompanied with a loss of protective reflexes * Provide safe, efficient and effective dental care * Eliminate anxiety * Reduce untoward movement * Aid in treatment of mentally, physically or medically compromised patient © Lisa S Jacob, DDS, MS 2009

Minimal Intervention * Modern medical approach to the management of oral disease * Early Diagnosis * Change environment * Repair © Lisa S Jacob, DDS, MS 2009

Early Detection Identify Assess any potential caries risk factors Recognition White spot lesions Gingivitis © Lisa S Jacob, DDS, MS 2009

Change Environment Prevent Minimize risk factors to prevent caries Rebalance oral environment Remineralize © Lisa S Jacob, DDS, MS 2009

RESTORE Restore tooth with bioactive materials Preserve tooth structure Repair http: //www. wpclipart. com/tools/hammer_1. png © Lisa S Jacob, DDS, MS 2009

Dental Restorative Material n Glass Ionomer n Composite n Amalgam n Resin Crown n Stainless steel crown © Lisa S Jacob, DDS, MS 2009

Glass Ionomer Restorations n n n Fluoride release Primary and permanent teeth Cement stainless steel crowns Orthodontic appliances Transitional restorations for caries control n n n Tooth isolation High caries risk Base © Lisa S Jacob, DDS, MS 2009

Resin-based composite Excellent restoration in primary and permanent dentition in low caries risk patient n May not be ideal for patient at high risk for dental decay n Donly KJ, Garcia-Godoy F. The use of resin-based composite in children. Pediatric Dentistry. 2002: 24; 480 -8. © Lisa S Jacob, DDS, MS 2009

Frequency of Radiographs Depends on caries risk of patient ADA/FDA Guidelines © Lisa S

Low Caries Risk Primary and Mixed Dentition Bitewings every 12 -24 months Adolescent with permanent dentition Bitewings every 18 -36 months Adult Dentate or partially edentulous Bitewings every 24 -36 months © Lisa S Jacob, DDS, MS 2009

High Caries Risk Child and adolescent with permanent dentitions Bitewings should be taken every 6 -12 months Adult dentate or Partially Edentulous Bitewings every 6 -18 months © Lisa S Jacob, DDS, MS 2009

Frequency of Recall Exam and Prophys Low Risk: Every year Moderate Risk: Every 6 months High risk: Every 3 months © Lisa S Jacob, DDS, MS 2009

Frequency of Prophylaxis Depends on caries risk of patient at discretion of practitioner. ©

Low Caries Risk Goal is to MAINTAIN Recall exam every year Radiographs Every 12 -18 months in primary teeth Every 2 years in permanent teeth Continue good diet and oral hygiene Daily use of fluoridated toothpaste © Lisa S Jacob, DDS, MS 2009

Moderate Caries Risk _ Goal is to REPAIR _ Recall every six months _ Radiographs every 18 -24 months _ Fluoride varnish every 6 months _ Daily use of xylitol or fluoride rinse _ Change Behavior by decreasing snacking © Lisa S Jacob, DDS, MS 2009

High Caries risk Goal is to REPAIR and RESTORE Recall every three months Radiographs every 6 -12 months Glass ionomer as an interim material Fluoride varnish every 3 months Chew 5 pieces of xylitol gum every day © Lisa S Jacob, DDS, MS 2009

High Caries Risk * Counsel on diet * Review oral hygiene instructions © Lisa

Take Home Messages for Parents Cavities are preventable Caries is an infectious disease Transmitted from parents/caregivers © Lisa S Jacob, DDS, MS 2009

Suggestions for Practitioners √ Be flexible √ Be consistent √ Be Compassionate √ PRAISE, PRAISE © Lisa S Jacob, DDS, MS 2009