2 - Oral Health Policies

Question 1

How is dental care medically necessary?

Answer 1

1. Dental care is medically necessary to prevent and eliminate orofacial disease, infection, and pain, to restore the form and function of the dentition and to correct facial disfiguration or dysfunction.
2. The US Surgeon General’s report emphasizes that oral health is integral to general health. Oral diseases can have a direct and devastating impact on overall health, especially for those with certain systemic health problems or conditions.

Question 2

What percent of children experience caries?

Answer 2

1. Approximately 60% of children experience caries in their primary teeth by age five.
   - -There is a significant increase in caries prevalence in the two to five year age range.
2. By 17 years of age, 78% of children in the US have experienced caries.

Question 3

Where do most of the caries occur in school aged children?

Answer 3

As much as 90% of all caries in school-aged children occurs in pits and fissures.

Question 4

What developmental problems is early childhood caries associated with?

Answer 4

Children with early childhood caries (ECC) may be severely underweight bc of the associated pain and disinclination to eat. Nutritional deficiencies during childhood can impact cognitive development.

Question 5

What systemic problems is periodontal disease associated with?

Answer 5

1. Cardiovascular disease

2. Adverse pregnancy outcomes

Question 6

What association is there between oral health and respiratory disease?

Answer 6

1. Oral health, oral microflora and bacterial pneumonia, especially in populations at high risk for respiratory disease, have been linked.
2. The mouth can harbor respiratory pathogens that may be aspirated, resulting in airway infections.

Question 7

How do infants and young children have unique caries-risk factors?

Answer 7

1. Ongoing establishment of oral flora and host defense systems
2. Susceptibility of newly erupted teeth
3. Development of dietary habits and childhood food preferences

Question 8

What can predispose children to have caries?

Answer 8

1. Children are most likely to develop caries if mutans streptococci is acquired at an early age.
2. High-risk caries-conducive dietary practices appear to be established early, probably by 12 months of age, and are maintained throughout early childhood.

Question 9

What percent of the US population does not benefit from community water fluoridation?

Answer 9

More than one-third of the US population does not benefit from community water fluoridation.

Question 10

What children benefit from sealants placed prophylactically?

Answer 10

Children with multiple risk factors and tooth morphology predisposed to plaque retention (i.e., developmental defects, pits and fissures).

Question 11

What reduction in caries does sealants provide?

Answer 11

A child who receives sealants is 72% less likely to receive restorative services over the next three years than children who do not.

Question 12

Are sealants on primary molars beneficial?

Answer 12

Sealants placement on primary molars in young children is a cost-effective strategy for children at risk for caries, including those insured by state Medicaid programs.

Question 13

What is the success rate of sealants with follow-up care?

Answer 13

With follow-up care, the success rate of sealants may be 80 to 90 percent, even after a decade.

Question 14

What percent of Medicaid programs reimburse dentists for sealants on primary molars?

Answer 14

While all Medicaid programs reimburse dentists for sealants on permanent teeth, only one in three reimburses for primary molar sealants.

Question 15

What are most of the insurance companies’ basis for refusal to provide reimbursement for sedation/general anesthesia and related facility services?

Answer 15

1. Most denials cite the procedure as “not medically necessary.” This determination appears to be based on arbitrary and inconsistent criteria.
2. American Dental Association Resolution 1989-546 states that insurance companies should not deny benefits that would otherwise be payable “solely on the basis of the professional degree and licensure of the dentist or physician providing treatment, if that treatment is provided by a legally qualified dentist or physician operating within the scope of his or her training and licensure.”

Question 16

What is the AAPD’s policy on medically necessary care?

Answer 16

The AAPD encourages:

1. Oral health care to be included in the design and provision of individual and community-based health care programs to achieve comprehensive health care.
2. Establishment of a dental home for all children by 12 months of age in order to institute an individualized preventive oral health program based upon each pt’s unique caries risk assessment.
3. Healthcare providers who diagnose oral diseases to either provide therapy or refer the pt to a primary care dentist or dental/medical specialist as dictated by the nature and complexity of the condition. Immediate intervention is necessary to prevent further dental destruction, as well as more widespread health problems.
4. Evaluation and care provided for an infant, child, or adolescent by a cleft lip/palate, orofacial or craniofacial deformities team as the optimal way to coordinate and deliver such complex services.
5. The dentist providing oral health care for a pt to determine the medical indication and justification for treatment. The dental care provider must assess the pt’s developmental level and comprehension skills, as well as the extent of the disease process, to determine the need for advanced behavior guidance techniques such as sedation or general anesthesia.

Question 17

What is the AAPD’s encouragement to third party payers?

Answer 17

The AAPD encourages third party payers to:

1. Recognize malformed and missing teeth are resultant anomalies of facial development seen in orofacial anomalies and may be from congenital defects. Just as the congenital absence of other body parts requires care over the lifetime of the pt, so will these.
2. Include oral health care services related to these facial and dental anomalies as benefits of health insurance without discrimination between the medical and dental nature of the congenital defect. These services, optimally provided by the craniofacial team, include, but are not limited to, initial appliance construction, periodic examinations, and replacement of appliances.
3. End arbitrary and unfair refusal of compensation for oral health care services related to orofacial and dental anomalies.
4. Recognize the oral health benefits of dental sealants and not base coverage for sealants on permanent and primary teeth on a pt’s age.
5. Ensure that all children have access to the full range of oral health delivery systems. If sedation or general anesthesia and related facility fees are payable benefits of a health care plan, these same benefits shall apply for the delivery of oral health services.
6. Regularly consult the AAPD with respect to the development of benefit plans that best serve the oral health interests of infants, children, adolescents and persons with special health care needs, especially those with craniofacial or acquired orofacial anomalies.

Question 18

What are the major themes in the US Surgeon General’s report on “Oral Health in America”?

Answer 18

1. Oral health means much more than healthy teeth.
2. Oral health is integral to general health.
3. Profound and consequential disparities exist in the oral health of our citizens.

Question 19

What are the recommendations in the DHHS report “National Call to Action to Promote Oral Health”?

Answer 19

It recommends:

1. Changing perceptions of the public, policymakers, and health providers regarding oral health and disease so that oral health becomes an accepted component of general health.
2. Removing known barriers between people and oral health services.
3. Accelerating the building of the scientific and evidence base, as well as the application of research findings, to improve oral health.
4. Ensuring the adequacy of public and private health personnel and resources to meet the oral health needs of all Americans and enable the integration of oral health effectively with general health. The focus is on having a responsive, competent, diverse and flexible workforce.
5. Expanding public-private partnerships and building upon common goals to improve the oral health of those who suffer disproportionately from oral diseases.

Question 20

According to the AAPD, AAP, ADA and Academy of General Dentistry, when should children first see the dentist?

Answer 20

1. Referral by the primary care physician or health provider has been recommended, based on risk assessment, as early as six months of age, six months after the first tooth erupts and no later than 12 months of age.
   - -This provides time-critical opportunities to provide education on preventive health practices and reduce a child’s risk of preventable dental/oral disease.

Question 21

What should a dental home provide?

Answer 21

1. Comprehensive oral health care including acute care and preventive services in accordance with AAPD periodicity schedules.
2. Comprehensive assessment for oral diseases and conditions.
3. Individualized preventive dental health program based upon a caries-risk assessment and a periodontal disease risk assessment.
4. Anticipatory guidance about growth and development issues (i.e., teething, digit or pacifier habits).
5. Plan for acute dental trauma.
6. Information about proper care of the child’s teeth and gingivae. This would include the prevention, diagnosis and treatment of disease of the supporting and surrounding tissues and the maintenance of health, function and esthetics of those structures and tissues.
7. Dietary counseling.
8. Referrals to dental specialists when care cannot directly be provided within the dental home.
9. Education regarding future referral to a dentist knowledgeable and comfortable with adult oral health issues for continuing oral health care; referral at an age determined by patient, parent and pediatric dentist.

Question 22

What concept is the dental home based on?

Answer 22

Derived from the AAP model of a medical home.

Question 23

What did the US Surgeon General’s report on “Oral Health in America: A Report of the Surgeon General” in 2000, say about the disparities in oral health?

Answer 23

1. The report identified profound and consequential disparities in the oral health of our citizens.
2. Dental disease restricts activities in schools, work and home and often significantly diminishes the quality of life.
3. For certain large groups of disadvantaged children there is a silent epidemic of dental disease.
   - -Dental caries is the most common chronic disease of children in the US.
   - -80% of tooth decay is found in 20-25% of children, large portions of whom live in poverty or low-income households and lack access to an on-going source of quality dental care.

Question 24

What factors contributes to access to care?

Answer 24

1. Health care professionals often elect not to participate as providers in Medicaid or CHIP programs due to:
   - -Low reimbursement rates
   - -Administration burdens
   - -Frequency of failed appointments by pts whose treatment is publicly funded
2. Underutilization of services due to:
   - -Lack of health literacy
   - -Limited English proficiency
   - -Cultural and societal barriers
3. Financial circumstances and geographical/transportational considerations.

Question 25

In the dental home model who directs the care?

Answer 25

1. Central to the dental home model is dentist-directed care.
   - -The dentist performs the examination, diagnoses oral conditions and establishes a treatment plan that includes preventive services, and all services are carried out under the dentist’s supervision.
2. The dental home delivery model implies direct supervision (i.e., physical presence during the provision of care) by the dentist.
   - -The allied dental personnel (e.g., dental hygienist, expanded function dental assistant/auxiliary (EFDA), dental assistant) work under direct supervision of the dentist to increase productivity and efficiency while preserving quality of care.
3. This model also allows for provision of preventive oral health education by EFDAs and preventive oral health services by a dental hygienist under general supervision (i.e., without the presence of the supervising dentist in the treatment facility) following the examination, diagnosis and treatment plan by the licensed, supervising dentist.
4. The dental team can be expanded to include auxiliaries who go into the community to provide education and coordination of oral health services.

Question 26

Why would the mid-level provider model not improve access to care for the underserved?

Answer 26

1. Current US proposed models are private practice/non-government employee models, providing no assurances that independent providers will locate in underserved areas.
   - -If providers are government employees, assignment to areas of greatest need is possible.
2. Evidence from several developed countries that have initiated mid-level provider programs suggests that, when afforded an opportunity, those practitioners often gravitate toward private practice settings in less-remote areas, thereby diminishing the impact on care for the underserved.

Question 27

How is the technical quality of restorative procedures performed by non-dentist providers?

Answer 27

1. Studies have found, in general, that within the scope of services and circumstances to which their practices are limited, the technical quality is comparable to that produced by dentists.
2. There is, however, no evidence to suggest that they deliver any expertise comparable to a dentist in the fields of diagnosis, pathology, trauma care, pharmacology, behavioral guidance, treatment plan development and care of special needs pts.
3. It is essential that policy makers recognize that evaluations which demonstrate comparble levels of technical quality merely indicate that individuals know how to provide certain limited services, not that those providers have the knowledge and experience necessary to determine whether and when various procedures should be performed or to manage individuals’ comprehensive oral health care, especially with concurrent conditions that may complicate treatment or have implications for overall health. Technical competence cannot be equated with long-term outcomes.

Question 28

What does the New Zealand model show about the use of non-dentist providers?

Answer 28

1. New Zealand, known for utilizing dental therapists since the 1920’s and frequently referenced as a workforce model for consideration in the US, recently completed its first nationwide oral health status survey in over 20 years.
2. The New Zealand caries rates, which are higher than the US, UK, and Australia, help refute a presumption that utilization of non-dentist providers will overcome the disparities.

Question 29

Does the AAPD support non-dentist providers?

Answer 29

1. AAPD encourages the greater use of expanded function dental assistants/auxiliaries and dental hygienists under direct supervision by a dentist to help increase volume of services provided within a dental home, based upon their proven effectiveness and efficiency in a wide range of settings.
2. AAPD also supports provision of preventive oral health services by a dental hygienist under general supervision (i.e., without the presence of the supervising dentist in the treatment facility) following examination, diagnosis and treatment plan by the licensed, supervising dentist.
3. Similarly, partnering with other health providers, especially those who most often see children during the first years of life (e.g., pediatricians, family physicians, pediatric nurses), will expand efforts for improving children’s oral health.
4. AAPD strongly believes there should not be a two-tiered standard of care, with our nation’s most vulnerable children receiving services by providers with less education and experience, especially when evidence-based research to support the safety, efficiency, effectiveness and sustainability of such delivery models is not available.

Question 30

What dental records are used for identification purposes?

Answer 30

1. Dental radiographs
2. Facial photographs
3. Study casts
4. Dental histories documenting teeth present and distinguishing features of oral structures.
5. Restorative history documenting restored surfaces and materials used.
6. Bite registrations

Question 31

What non-dental sources are used for identification purposes?

Answer 31

1. Fingerprints
2. Photographs
3. Physical descriptions
4. DNA from blood, saliva and other tissue

Question 32

What programs have been developed by community groups that use child identification methods?

Answer 32

1. Child Identification Program (CHIP) - sponsored by the Masons. this program gathers saliva samples for DNA fingerprinting, videos, toothprints and fingerprints
2. The National Child Identification Program - sponsored by the American Football Coaches Association with the Optimist International and Clear Channel Int. They use an identification card which includes fingerprints, a physical description, photographs and the physician’s office address/telephone number.
3. New England Kids Identification System (KIDS) - sponsored by the Massachusetts Free Masons and the Massachusetts Dental Society, which incorporated dental bite impression and cheek swabs to gather DNA material into the CHIP events.

Question 33

What percent of children receive some form of child care on a regular basis from persons other than their parents?

Answer 33

In the US in 2005, 61% of children ages 0 through 6 who were not yet in kindergarten received some form of child care on a regular basis from persons other than their parents.

Question 34

Of the children who receive some form of child care from persons other than their parents, on a regular basis, what percent attended center-based programs?

Answer 34

57% of the children who received some form of child care on a regular basis from persons other than their parents attended center-based programs which include day care centers, pre-kindergartens, nursery schools, Head Start programs and other early childhood education programs.

Question 35

What are the organizations that have recommendations and requirements that address oral health in out-of-home child care?

Answer 35

1. The American Academy of Pediatrics
2. The American Public Health Association
3. The National Association for the Education of Young Children (NAYEC)
4. Head Start

Question 36

By the time children begin kindergarten, what percent have caries?

Answer 36

40%

Question 37

What is the most common chronic disease of childhood?

Answer 37

ECC is the most common chronic disease of childhood, affecting 28% of children 2 to 5 years of age, or over four million children nationwide.

Question 38

What does the AAPD encouragement to child care centers?

Answer 38

1. Utilize oral health consultation, preferably by a pediatric dentist, at least once a year and as needed. The health consultant should review and observe program practices regarding oral health and make individualized recommendations for each program.
2. Promote the concept of the dental home by educating their personnel as well as the parents on the importance of oral health and providing assistance with establishment of a dental home no later than 12 months of age of the child.
3. Maintain a dental record, starting at 12 months with yearly updates, as part of the child’s health report. It should address the child’s oral health needs including any special instructions given to the care givers.
4. Have written up-to-date, comprehensive procedures to prepare for, report, and respond to medical and dental emergencies. The source of urgent care should be known to caregivers and acceptable to parents.
5. Sponsor on-site, age-appropriate oral health education programs for the children that will promote good oral hygiene and dietary practices, injury prevention and the importance of regularly scheduled dental visits.
6. Provide in-service training programs for personnel regarding oral hygiene concepts, proper nutrition choices, link between diet and tooth decay and children’s oral health issues including proper initial response to traumatic injuries along with dental consequences. Personnel with an understanding of these concepts are at a greater advantage in caring for children.
7. Encourage parents to be active partners in their children’s health care process and provide an individualized education plan, one that is sensitive to cultural values and beliefs, to meet every family’s needs. Written material should be available and, at a minimum, address oral health promotion and disease prevention and the timing of dental visits.
8. Familiarize parents with the use of and rationale for oral health procedures administered through the program and obtain advance parental authorization for such procedures.
9. Incorporate an oral health assessment as part of the daily health check of each child.
10. Promote supervised or assisted oral hygiene practices at least once daily after a meal or a snack.
11. Provide well-balanced and nutrient-dense diets of low caries-risk.
12. Have clean, optimally-fluoridated drinking water available for consumption throughout the day.
13. Not permit infants and toddlers to have bottles/sippy cups in the crib or to carry them while walking or crawling while under the child care center’s supervision.
14. Minimize saliva-sharing activities (e.g., sharing utensils, orally cleansing a pacifier) to help decrease an infant’s or toddler’s acquisition of cariogenic microbes.

Question 39

How many states require a dental screening examination prior to school matriculation?

Answer 39

Only 11 states and the District of Columbia require a dental screening examination prior to school matriculation.

Question 40

Low-income children account for what percent of ECC?

Answer 40

33% of low-income children experience 75% of the ECC.

Question 41

What is the average number of school days missed from acute dental problems?

Answer 41

In 1996, students aged 5 to 17 missed an average of 3.1 days/100 students due to acute dental problems.
–When these problems are treated and children no longer are experiencing pain, their learning and school attendance improve.

Question 42

What does the AAPD recommend for a comprehensive oral health exam prior to matriculation into school?

Answer 42

Documentation of:

1. Oral health history
2. Soft tissue health/pathologic conditions
3. Oral hygiene level
4. Variations from a normal eruption/exfoliation pattern
5. Dental dysmorphology or discoloration
6. Caries (including white-spot lesions)
7. Existing restorations

Education on:
1. The child/parent should be made aware of age-related caries-risk and caries-protective factors, as well as the benefits of a dental home.

Question 43

What does the National Association of State Boards of Education state about health and school?

Answer 43

The National Association of State Boards of Education recognizes that health and success in school are interrelated. Schools cannot achieve their primary mission of education if students and staff are not healthy and fit physically, mentally and socially.

Question 44

What does the US Surgeon General state about the national health plan for oral health?

Answer 44

A national public health plan for oral health does not exist.

• -There is no national national policy on excused absences from school for dental appointments.
• -Some states (e.g., California, Texas) have very specific laws excusing students for dental appointments. Other state laws are more general and recognize absences due to doctor’s appointments or illness.

Question 45

What is the AAPD’s policy on school absences for dental appointments?

Answer 45

The AAPD:

1. Supports state law or school policy that allows the absence for legitimate healthcare delivery, including that of oral health services.
2. Encourages parents, school administrators dentists to work together to ensure that children receive dental care while minimizing school absences.

Question 46

What is the ADA and AAPD recommendation for emergency dental care?

Answer 46

1. ADA Principles of Ethics and Code of Professional Conduct states that “dentists shall be obliged to make reasonable arrangements for the emergency care of their patients of record.”
2. AAPD recommends dentists should provided instructions to the parent for accessing emergency care.
   - -When consulted for a dental emergency by patients not of record, the dentist should make reasonable arrangements for emergency dental care.
   - -If emergency dental treatment is provided, the dentist should recommend that the patient return to his/her dental home unless the parent expresses a different preference.

Question 47

Is there a difference between fluoride treatment before and after prophylaxis?

Answer 47

1. Over the years, there have been numerous reports showing plaque and pellicle are not a barrier to fluoride uptake in enamel and, consequently,
2. There is no evidence of a difference in caries rate or fluoride uptake in subjects who receive rubber cup prophylaxis or a tooth brush prophylaxis before fluoride treatment.

Question 48

What is selective polishing and why is there increased popularity in selective polishing?

Answer 48

1. Selective polishing procedure involve individual evaluation of each pt so that only specific teeth that have indications (e.g., stain) receive a rubber cup pumice prophylaxis
2. The potential for abrasives causing tooth wear and loss of the fluoride-rich zone of enamel has been cited as a consideration for decreasing the need for pumice prophylaxis. As a result, the selective polishing procedure and the toothbrush prophylaxis procedure have gained popularity..

Question 49

What is the benefit of a professional prophylaxis?

Answer 49

Professional prophylaxis is indicated to:

1. Instruct the caregiver and child or adolescent in proper oral hygiene techniques.
2. Remove microbial plaque, extrinsic stain and calculus.
3. Facilitate the examination of hard and soft tissues.
4. Introduce dental procedures to the young child and apprehensive pt.
5. Assess pt cooperation.

Question 50

Which prophylaxis option can remove stain?

Answer 50

1. Rubber cup
2. Hand instruments
3. Ultrasonic scalers

Question 51

Which prophylaxis options can remove calculus?

Answer 51

1. Hand instruments

2. Ultrasonic scalers

Question 52

What is the most beneficial and inexpensive method of reducing the occurrence of caries?

Answer 52

The adjustment of the fluoride level in community water supplies to optimal concentration is the most beneficial and inexpensive method of reducing the occurrence of caries.

Question 53

How much reduction in fluoride has water fluoridation provided?

Answer 53

1. Epidemiologic data from the last half-century indicate reductions in caries of 55 to 60 percent.
2. Recent data show caries reduction of approximately 25 percent, without significant enamel fluorosis, when domestic water supplies are fluoridated at an optimal level.

Question 54

How much reduction in the cost of oral health care for children has water fluoridation provided?

Answer 54

Evidence accumulated from long-term use of fluorides has demonstrated that the cost of oral health care for children can be reduced by as much as 50 percent.

Question 55

If effective fluoridation of drinking water is impossible, what can you do?

Answer 55

When fluoridation of drinking water is impossible, effective systemic fluoridation can be achieved through the intake of daily fluoride supplements.
–Before supplements are prescribed, it is essential to review dietary sources of fluoride (e.g., all drinking water sources, consumed beverages, prepared food, toothpaste) to determine the pt’s true exposure to fluoride.

Question 56

What is the concern with infant formula and fluoride?

Answer 56

1. Fluoride content of ready to use infant formulas in the US and Canada ranges from 0.1 to 0.3 mg/L, which provides only a modest source of fluoride.
2. The more important issue, however, is the fluoride content of concentrated or powdered formula when reconstituted with fluoridated water.
   - -Considering the potential for mild fluorosis, caution is advised for infants consuming formula that is reconstituted with optimally-fluoridated water.
   - -As the Environmental Protection Agency/Department of Health and Human Services’ recommendation for optimizing community water supplies to 0.7ppm F is instituted, fluorosis due to reconstituting infant formula with fluoridated water will be less of an issue.

Question 57

Numerous clinical trials have confirmed the anti-caries effect of which professional topical fluoride treatments?

Answer 57

Numerous clinical trials have confirmed the anti-caries effect of professional topical fluoride treatments, including:

• -1.23% acidulated phosphate fluoride
• -5% neutral sodium fluoride varnish
• -0.09% fluoride mouthrinse
• -0.5% fluoride gel/paste

Question 58

How much fluoride toothpaste should be used for tooth brushing in children?

Answer 58

1. No more than a smear or rice-size (0.1mg fluoride) amount for children less than 3 years of age.
2. No more than a pea-size (0.25mg fluoride) amount for children aged 3 to 6.

Question 59

What is the most effective method for reducing dental caries prevalence in children?

Answer 59

Drinking fluoridated water and brushing with fluoridated toothpaste at least daily are perhaps the most effective method in reducing dental caries prevalence in children.

Question 60

What is the chemical structure of xylitol?

Answer 60

1. Xylitol is a five-carbon sugar alcohol derived primarily from forest and agricultural materials.
2. It is found naturally in various trees, fruits and vegetables and is an intermediate product of the glucose metabolic pathway in man and animal.

Question 61

What has xylitol been historically used for?

Answer 61

It has been used since the early 1960s in:

1. Infusion therapy for post-operative burn and shock patients.
2. Diet of diabetic patients.
3. Sweetener in products aimed at improved oral health.

Question 62

What is the optimal amount of xylitol intake for anticariogenic results?

Answer 62

1. Studies suggest xylitol intake that consistently produces positive results ranged from 4-10g/day, divided into 3-7 consumption periods.
   - -Higher amounts did not result in greater reduction in incidence of caries and may lead to diminishing anticariogenic results.
   - -Consumption frequency of less than 3 times per day at optimal xylitol amount showed no effect.

Question 63

What are the side effects of xylitol?

Answer 63

Abdominal distress, gas and osmotic diarrhea have been reported following the ingestion of xylitol.

• -Diarrhea has been reported in pts who have consumed 3-60g of xylitol per day.
• These symptoms usually occur at higher dosages and will subside once xylitol consumption is stopped.
• To minimize gas and diarrhea, xylitol should be introduced slowly, over a week or more, to acclimate the body to the polyol, especially in young children.

Question 64

How does xylitol have an anticariogenic effect?

Answer 64

1. Reduces plaque formation and bacterial adherence (i.e., is antimicrobial)
2. Inhibits enamel demineralization (i.e., reduces acid production)
3. Has a direct inhibitory effect on MS - disrupts the energy production processes of MS leading to a futile energy consumption cycle and cell death.

Question 65

What happens with prolonged use of xylitol?

Answer 65

Prolonged use of xylitol appears to select for a “xylitol resistant” mutant of the MS cells.

• -These mutants appear to shed more easily into saliva than the parent strains, resulting in a reduction of MS in plaque and possibly hampering their transmission/colonization from mother to child.
• -Long lasting effects have been demonstrated up to five years after two years of using xylitol chewing gum.

Question 66

What delivery vehicles is xylitol available in?

Answer 66

1. Gums
2. Mints
3. Chewable tablets
4. Lozenges
5. Toothpastes
6. Mouthwashes
7. Cough mixtures
8. Nutraceutical products

Xylitol chewing gum has been shown to be effective as a preventive agent. The effectiveness of other xylitol products is being studied at this time.

Question 67

What is the difference between ART and ITR?

Answer 67

1. Atraumatic/alternative restorative technique (ART) is a means of restoring and preventing caries in populations with little access to traditional dental care.
   - -In many countries, practitioners provide treatment in non-traditional settings that restrict restorative care to placement of provisional restorations.
   - -Bc circumstances do not allow for follow-up care, ART mistakenly has been interpreted as a definitive restoration.
2. Interim therapeutic restoration (ITR) utilizes similar techniques but has different therapeutic goals.
   - -ITR more accurately describes the procedures used in contemporary dental practice in the US>

Question 68

When is ITR used?

Answer 68

ITR may be used to restore and prevent carious lesions in:

1. Young patients
2. Uncooperative patients
3. Patients with special health care needs
4. When traditional cavity preparation and/or placement of traditional dental restorations are not feasible and need to be postponed
5. May be used for step-wise excavation in children with multiple open carious lesions prior to definitive restoration of the teeth, in erupting molars when isolation conditions are not optimal for a definitive restoration, or in patients with active lesions prior to treatment performed under general anesthesia.

Question 69

How much reduction in cariogenic oral bacteria does ITR provide?

Answer 69

ITR has been shown to reduce the levels of cariogenic oral bacteria (e.g., Mutans Streptococci, lactobacilli) in the oral cavity immediately following its placement.
–However, this level may return to pretreatment counts over a period of six months after ITR placement if no other treatment is provided.

Question 70

ITR is most successful with what kind of caries?

Answer 70

ITR has the greatest success when applied to single surface or small two surface restorations.

Question 71

How can ITR restorations fail?

Answer 71

Inadequate cavity preparation with subsequent lack of retention and insufficient bulk can lead to failure.

Question 72

Why was the term “Nursing Bottle Caries” renamed to ECC?

Answer 72

The distinctive clinical presentation was not consistently associated with poor feeding practices and that caries was an infectious disease. The AAPD adopted the term ECC to reflect better its multifactorial etiology.

Question 73

What is ECC?

Answer 73

The presence of one or more decayed (noncavitated or cavitated lesions), missing (due to caries) or filled tooth surfaces in any primary tooth in a child under the age of six.

Question 74

What is S-ECC?

Answer 74

1. In children younger than three years old, any signs of smooth-surface caries is indicative of severe early childhood caries (S-ECC).
2. From ages 3-5, one or more cavitated, missing, or filled smooth surfaces in primary maxillary anterior teeth or a decayed, missing, or filled score of greater than or equal to four (age 3), greater than or equal to five (age 4), or greater than or equal to six (age 5) surfaces also constitutes S-ECC.

Question 75

What are the consequences of ECC?

Answer 75

1. Higher risk of new carious lesions in both the primary and permanent dentitions.
2. Hospitalizations and emergency room visits.
3. Increased treatment costs.
4. Risks for delayed physical growth and development.
5. Loss of school days and increased days with restricted activity.
6. Diminished ability to learn.
7. Diminished oral health-related quality of life.

Question 76

How is MS transmitted?

Answer 76

1. Vertically from caregiver to child through salivary contact, affected by the frequency and amount of exposure. Infants whose mothers have high levels of MS, a result of untreated caries, are at greater risk of acquiring the organism earlier than children whose mothers have low levels.
2. Horizontally (e.g., between other members of a family or children in daycare). Eliminating saliva-sharing activities (e.g., sharing utensils, orally cleansing a pacifier) may help decrease an infant’s or toddler’s acquisition of cariogenic microbes.

Question 77

How are newly erupted teeth more susceptible to caries?

Answer 77

They have immature enamel.

Question 78

What is the best way to maximize the beneficial effect of fluoride in toothpaste?

Answer 78

Rinsing after brushing should be kept to a minimum or eliminated altogether.

Question 79

What is the recommended professionally-applied fluoride treatment for children at risk for ECC who are younger than six years old?

Answer 79

5% sodium fluoride varnish (NAFV; 22,500ppm F)

Question 80

What are the dietary risk factors for ECC?

Answer 80

1. Frequent night time bottle feeding with milk and ad libitum breast-feeding are associated with, but not consistently implicated in, ECC.
   - -Breastfeeding greater than or equal to 7 times daily after 12 months of age is associated with increased risk for ECC.
   - -Ad libitum breastfeeding after introduction of other dietary carbohydrates and inadequate oral hygiene are risk factors for ECC.
2. Night time bottle feeding with juice, repeated use of a sippy or no-spill cup, and frequent in between meal consumption of sugar-containing snacks or drinks (e.g., juice, formula, soda) increase the risk of caries.

Question 81

Is breast milk cariogenic?

Answer 81

While ECC may not arise from breast milk alone, breast feeding in combination with other carbohydrates has been found in vitro to be highly cariogenic.

• -Breastfeding greater than or equal to 7 times daily after 12 months of age is associated with increased risk for ECC.
• -Ad libitum breastfeeding after introduction of other dietary carbohydrates and inadequate oral hygiene are risk factors for ECC.

Question 82

What is the AAP recommendation on how much juice children can drink?

Answer 82

The AAPD has recommended children 1-6 years of age consume no more than 4-6 ounces of fruit juice per day, from a cup (i.e., not a bottle or covered cup) and as part of a meal or snack.

Question 83

The AAPD encourages what preventive measures to decrease the risk of developing ECC?

Answer 83

1. Reducing the parent/sibling’s MS levels to decrease transmission of cariogenic bacteria.
2. Minimizing saliva-sharing activities (e.g., sharing utensils) to decrease the transmission of cariogenic bacteria.
3. Implementing oral hygiene measures no later than the time of eruption of the first primary tooth. Toothbrushing should be performed for children by a parent twice daily, using a soft toothbrush of age-appropriate size. In all children under the age of three, a “smear” or “rice-size” amount of fluoridated toothpaste should be used. In all children ages three to six, a “pea-size” amount of fluoridated toothpaste should be used.
4. Providing professionally-applied fluoride varnish treatments for children at risk for ECC.
5. Establishing a dental home within six months of eruption of the first tooth and no later than 12 months of age to conduct a caries risk assessment and provide parental education including anticipatory guidance for prevention of oral diseases.
6. Avoiding high frequency consumption of liquids and/or solid foods containing sugar. In particular:
   - -Sugar-containing beverages (e.g., juices, soft drinks, sweetened tea, milk with sugar added) in a baby bottle or no-spill training cup should be avoided.
   - -Infants should not be put to sleep with a bottle filled with milk or liquids containing sugars.
7. Working with medical providers to ensure all infants and toddlers have access to dental screenings, counseling and preventive procedures.
   - -Ad libitum breast-feeding should be avoided after the first primary tooth begins to erupt and other dietary carbohydrates are introduced.
   - -Parents should be encouraged to have infants drink from a cup as they approach their first birthday. Infants should be weaned from the bottle between 12 to 18 months of age.

Question 84

When should prevention of ECC begin?

Answer 84

During the prenatal and perinatal periods.

• -Women should be advised to optimize nutrition during their pregnancy and the infant’s first year, when enamel is undergoing maturation.
• -Enamel defects are common in children with low birthweight or systemic illness or undernutrition during the perinatal period.

Question 85

What are the nutritional benefits of breast milk?

Answer 85

Human milk and breast-feeding of infants provide general health, nutritional, developmental, psychological, social, economic and environmental advantages while significantly decreasing risk for a large number of acute and chronic diseases.

Question 86

What percent of children are obese?

Answer 86

Results from a study in 2007-2008 that measured height and weight estimated 16.9% of children and adolescents in the US aged 2 through 19 were obese.
–Ethnically, the lowest was 14.5% among non-Hispanic white girls to the highest 26.8% among Mexican-American boys.

Question 87

What health risk predispositions are associated with childhood overweight and obesity?

Answer 87

1. Type II diabetes
2. Cardiovascular disease (hypertension, hypercholesterolemia and dyslipidemia)
3. Psychological stress (depression and low self-esteem)
4. Respiratory (obstructive sleep apnea and asthma)
5. Orthopedic (genu varum and slipped capital femoral epiphysis)
6. Hepatic (steatohepatitis)

Question 88

How does excessive fruit juice consumption affect development?

Answer 88

Excessive consumption of fruit juice has been associated with small stature in some children.

Question 89

According to the AAP, what is the recommended optimal way to obtain adequate amounts of vitamins?

Answer 89

The AAP has recommended that the optimal way to obtain adequate amounts of vitamins is to consume a healthy and well-balanced diet.

Question 90

What is the USDA and DHHS Dietary Guidelines for Americans?

Answer 90

1. Eating a variety of nutrient-dense foods and beverages.
2. Balancing foods eaten with physical activity to maintain a healthy body mass index.
3. Maintaining a caloric intake adequate to support normal growth and development and to reach or maintain a healthy weight.
4. Choosing a diet with plenty of vegetables, fruits and whole grains and low in fat, saturated (especially trans-saturated) fat and cholesterol.
5. Using sugars and salt (sodium) in moderation.

Question 91

How are carbonated drinks worse than sweetened drinks?

Answer 91

The acids present in carbonated beverages can have a greater deleterious effect (i.e., erosion) on enamel than the acids generated by oral flora from the sugars present in sweetened drinks.

Question 92

What effects have soft drinks (sodas, fruit juices and sports drinks) had on teenage girls?

Answer 92

As teenage girls have increased their consumption of soft drinks, their consumption of milk has decreased by 40%, which may contribute to a decrease in bone density, subsequent increase in fractures and future risk of osteoporosis.

Question 93

What is “pouring rights”?

Answer 93

In exchange for money to individual school or districts, “pouring rights contracts” give beverage companies exclusive rights to sell their products at school events and place vending machines on school property, along with other measures that increase student exposure to the beverages.

Question 94

What is the role of tobacco and death?

Answer 94

1. Tobacco is a risk factor for six of the eight leading causes of deaths in the world and kills up to one-half of is users.
2. The US Surgeon General’s report states that smoking is the single greatest avoidable cause of death. This report concludes that even in nonsmokers, secondhand smoke exposure causes disease and death.
3. 440,000 deaths per year are from smoking and an additional 50,000 deaths per year are from secondhand smoke.

Question 95

What percent of high school students use tobacco?

Answer 95

Tobacco use among high school students is 20% or 3.5 million, while 19.8% of adults smoke.

Question 96

What systemic sequelae are from tobacco use?

Answer 96

1. Cardiovascular disease
2. Reproductive effects
3. Pulmonary disease
4. Cancers of the cervix, kidney, pancreas, stomach, lung, larynx, bladder and esophagus
5. Leukemia
6. Cataracts
7. Abdominal aortic aneurysm
8. Bronchitis
9. Other lung diseases including pneumonia

Question 97

What systemic sequelae are from secondhand smoke?

Answer 97

1. Cardiovascular disease and lung cancer are increased by 25-30% in nonsmokers who inhale secondhand smoke.
2. Sudden infant death syndrome (SIDS), acute respiratory infections, middle ear infections, bronchitis, pneumonia, asthma, allergies and infections are risk factors in infants and children who are exposed to smoke.
3. Caries in the primary dentition also is related to secondhand smoke exposure.
4. Enamel hypoplasia in both the primary and permanent dentition also is seen in children exposed to cigarette smoke.

Question 98

What is “thirdhand” smoke and how does it affect children?

Answer 98

1. Thirdhand smoke describes the particulate residual toxins that are deposited in layers all over the home after a cigarette has been extinguished.
2. These volatile compounds are deposited and “off gas” into the air over months. Since children inhabit these low-lying contaminated areas and bc the dust ingestion rate in infants is more than twice that of an adult, they are even more susceptible to thirdhand smoke.
   - -Studies have shown that these children have associated cognitive defects in addition to the other associated risks of secondhand smoke exposure.

Question 99

Tobacco can result in what oral diseases?

Answer 99

1. Oral cancer
2. Periodontitis
3. Compromised wound healing
4. A reduction in the ability to smell and taste
5. Smoker’s palate and melanosis
6. Coated tongue
7. Staining of teeth and restorations
8. Implant failure
9. Leukoplakia

Question 100

What oral diseases is smokeless tobacco a risk factor for?

Answer 100

Smokeless tobacco is a risk factor for periodontal conditions and oral cancer.

Question 101

When does the initiation of tobacco use begin?

Answer 101

Initiation of tobacco use begins before age 19 for 90% of adult smokers.
–In fact, most studies show that people who do not use tobacco as a teen never use it.

Question 102

What factors contribute to the initiation of tobacco use during childhood and adolescence?

Answer 102

1. Aggressive marketing of tobacco products by manufacturers
2. Smoking by parents
3. Peer influenced
4. A functional belief in the benefits and normalcy of tobacco
5. Availability and price of tobacco products
6. Low socioeconomic status
7. Low academic achievement
8. Lower self-image
9. Lack of behavioral skills to resist tobacco offers

Question 103

Is there a safe exposure level to environmental tobacco smoke (ETS)?

Answer 103

No. Environmental tobacco smoke is a known human carcinogen and there is no evidence to date of a safe exposure level to ETS (secondhand or passive smoke).

Question 104

Intraoral jewelry or other oral accessories may lead to what oral conditions?

Answer 104

1. Increased plaque levels
2. Gingival inflammation and/or recession
3. Caries
4. Diminished articulation
5. Metal allergy

Question 105

Oral piercings involving the tongue, lips, cheeks and uvula have been associated with what pathological conditions/complications?

Answer 105

1. Pain
2. Infection
3. Scar formation
4. Tooth fractures
5. Metal hypersensitivity reactions
6. Localized periodontal disease
7. Speech impediment
8. Nerve damage

Question 106

What life-threatening complications are associated with oral piercings?

Answer 106

1. Bleeding
2. Edema
3. Endocarditis
4. Airway obstruction

Question 107

What diseases may be transmitted by unregulated piercing parlors and techniques?

Answer 107

1. Hepatitis
2. Tetanus
3. Tuberculosis
4. Bacterial endocarditis in susceptible pts

Question 108

Sports accidents account for what percent of all dental injuries in children?

Answer 108

10-39% of all dental injuries in children

Question 109

At what ages are children most susceptible to oral injury?

Answer 109

7-11 years old

Question 110

What sports have mandated good injury protection and which sports lag behind in injury protection?

Answer 110

1. Good injury protection:
   - -Football
   - -Lacrosse
   - -Ice hockey
2. Lag behind in injury protection:
   - -Baseball
   - -Basketball
   - -Soccer
   - -Softball
   - -Wrestling
   - -Volleyball
   - -Gymnastics

Question 111

What sports have the highest incidence of sports-related dental injuries in children?

Answer 111

1. Baseball and basketball have the highest incidence of sports related dental injuries in children 7-17 years old.
   - -Baseball – highest incidence within the 7-12 year old age group
   - -Basketball – highest incidence within the 13-17 year old age group

Question 112

What consumer sports product is most commonly related to dental injuries in children?

Answer 112

The bicycle

Question 113

What is the AAP’s recommendation on the trampoline?

Answer 113

1. AAP advises pts and their families against recreational trampoline use and that current safety measures have not decreased injury rates significantly.
2. AAP states that practitioners should only endorse use of trampolines as part of a structured training program with appropriate coaching, supervision and safety measures in place.

Question 114

What areas and teeth are most affected by orofacial injuries?

Answer 114

The majority of sport-related dental and orofacial injuries affect the upper lip, maxilla and maxillary incisors.
–50-90% of dental injuries involve the maxillary incisors.

Question 115

Can a mouthguard protect dentoalveolar injuries?

Answer 115

Yes it can but even with a mouthguard in place, up to 25% of dentoalveolar injuries can still occur.

Question 116

What orthodontic issue is a risk factor for dental trauma? At what severity should orthodontic treatment be initiated?`

Answer 116

1. The frequency of dental trauma is significantly higher for children with increased overjet and inadequate lip coverage.
2. Initiating preventive orthodontic treatment in early- to middle-mixed dentition of pts with an overjet greater than 3mm has the potential to reduce the severity of traumatic injuries to permanent incisors.

Question 117

What protective equipment has been shown to reduce both the frequency and severity of dental and orofacial trauma?

Answer 117

1. Helmets
2. Facemasks
3. Mouthguards

Question 118

The National Federation of State High School Associations mandates mouthguards for which sports?

Answer 118

1. Football
2. Ice hockey
3. Lacrosse
4. Field hockey
5. Wrestlers wearing braces

Question 119

What dental injuries can the mouthguard protect from?

Answer 119

1. Protect the lips and intraoral tissues from bruising and laceration
2. Protect the teeth from crown fractures, root fractures, luxations and avulsions
3. Protect the jaw from fracture and dislocations
4. Provide support for edentulous space

Question 120

How does the mouthguard work?

Answer 120

The mouthguard works by absorbing the energy imparted at the site of impact and by dissipating the remaining energy.

Question 121

According to the American Society for Testing Materials (ASTM), what are the categories of mouthguards?

Answer 121

Custom-fabricated > Mouth-formed/Boil-and-bite > Stock

1. Type I – Custom fabricated mouthguards
   - -Are produced on a dental model of the pt’s mouth by either the vacuum-forming or heat-pressure lamination techniques.
   - -For maximum protection, cushioning and retention, the mouthguard should cover all teeth in at least one arch, customarily the maxillary arch, less the third molar.
   - —-A mandibular mouthguard is recommended for individuals with a Class III malocclusion.
   - -The custom-fabricated type is superior in retention, protection and comfort.
2. Type II – Mouth-formed, also known as “boil-and-bite”
   - -Are made from thermoplastic material adapted to the mouth by finger, tongue and biting pressure after immersing the appliance in hot water.
   - -Available commercially at department and sporting-goods stores.
   - -These are the most commonly used among athletes but vary greatly in protection, retention, comfort and cost.
3. Type III – Stock mouthguards
   - -Designed for use without any modification and must be held in place by clenching the teeth together to provide a protective benefit.
   - -Clenching a stock mouthguard in place can interfere with breathing and speaking and, for this reason, stock mouthguards are considered by many to be less protective.
   - —-Despite these shortcomings, the stock mouthguard could be the only option possible for pts with particular clinical presentations (e.g., use of orthodontic brackets and appliances, periods of rapidly changing occlusion during mixed dentition).

Question 122

What is important about the occlusion when fabricating a mouthguard?

Answer 122

1. Proper anterior occlusion – this will prevent or reduce injury by better absorbing and distributing the force of impact.
2. The practitioner should also consider the pt’s vertical dimension of occlusion, personal comfort and breathing ability.

Question 123

When is a block-out method used to incorporate space to accommodate for future tooth movement and dental development?

Answer 123

1. Continual shifting of teeth in orthodontic therapy
2. Exfoliation of primary teeth
3. Eruption of permanent teeth

Question 124

What is the cost of a mouthguard?

Answer 124

In a 2004 national fee survey, custom mouthguards ranged from $60 to $285.

Question 125

What percent of parents are willing to pay for a mouthguard?

Answer 125

Only 24% of surveyed parents were willing to pay $25 for a custom mouthguard.

Question 126

What percent of children wear a mouthguard when it is available?

Answer 126

In a study of children receiving mouthguards at no cost, 29% never wore the mouthguard, 32% wore it occasionally, 15.9% wore it initially but quit wearing it after one month and only 23.2% wore the mouthguard when needed.

Question 127

What are the clinical indications for internal or external dental whitening?

Answer 127

1. Discoloration resulting from traumatic injury (i.e., calcific metamorphosis, darkening with devitalization).
2. Irregularities in enamel coloration of a permanent tooth due to trauma or infection of the related primary tooth.
3. Intrinsic discoloration/staining (e.g., fluorosis, tetracycline staining).
4. A negative self-image due to a discolored tooth or teeth.

Question 128

What are the advantages of in-office whitening or whitening products dispensed and monitored by a dental professional?

Answer 128

1. An initial professional examination to help identify causes of discoloration and clinical concerns with treatment (e.g., existing restorations, side effects).
2. Professional control and soft-tissue protection.
3. Patient compliance.
4. Rapid results.

Question 129

What over-the-counter products are available for at home dental bleaching use?

Answer 129

1. Bleaching gels
2. Whitening strips
3. Brush on agents
4. Toothpaste
5. Mints
6. Chewing gum
7. Mouth rinse

Question 130

How much peroxide is in professional vs at-home products?

Answer 130

1. Professional-use products usually range from 10-38% carbamide peroxide (equivalent to about 3-13% hydrogen peroxide).
2. Home-use products contain lower concentrations of hydrogen peroxide or carbamide peroxide.

Question 131

How does whitening toothpaste whiten teeth?

Answer 131

They contain polishing or chemical agents to improve tooth appearance by removing extrinsic stains through gentle polishing, chemically chelating, or other nonbleaching action.

Question 132

What are the side effects from bleaching vital teeth?

Answer 132

1. Tooth sensitivity – affects 8-66% of pts and often occurs during the early stages of treatment.
2. Tissue irritation – results from an ill-fitting tray rather than the bleaching agents and resolves once a more accurately fitted tray is used.
3. Increased marginal leakage of an existing restoration

–Both sensitivity and tissue irritation usually are temporary and cease with the discontinuance of treatment.

Question 133

What are the side effects from bleaching nonvital teeth?

Answer 133

1. Internal bleaching
   - -External root resorption
   - -Anklylosis
2. External bleaching
   - -Increased marginal leakage of an existing restoration

Question 134

What harmful byproducts can occur with hydrogen peroxide or carbamide peroxide?

Answer 134

1. One of the degradation byproducts of hydrogen peroxide or carbamide peroxide results in a hydroxyl-free radical. This byproduct has been associated with periodontal tissue damage and root resorption.
2. Due to the concern of the hydroxyl free radical and the potential side effects of dental bleaching, minimizing exposure at the lowest effect concentration of hydrogen peroxide or carbamide peroxide is recommended.

Question 135

What is the problem with using sodium perborate for bleaching?

Answer 135

1. Current literature and clinical studies support the use of sodium perborate mixed with water for bleaching nonvital teeth.
2. Studies have shown higher incidences of root resorption when hydrogen peroxide is mixed with sodium perborate or any mixture of sodium perborate is heated.
   - -Therefore, the use of hydrogen peroxide and heating any mixture of sodium perborate are not recommended.

Question 136

What is the first laser specifically for dental use?

Answer 136

Neodymium-ytrium-aluminum-garnet (Nd:YAG) laser, developed in 1987 and approved by the FDA in 1990.

Question 137

What is a laser and how does it work?

Answer 137

1. The term laser is an acronym for light amplification by stimulated emission of radiation.
2. Within a laser, an active medium is stimulated to produce photons of energy that are delivered in a beam with an exact wavelength unique to that medium.
3. The energy radiated by the laser is basically a light of one color (monochromatic) and thus a single wavelength.
   - -Oral hard and soft tissue have a distinct affinity for absorbing laser energy of a specific wavelength. The wavelength of a dental laser is the determining factor of the level to which the laser energy is absorbed the intended tissue.
   - -Target or identified tissues differ in their affinity for specific wavelengths of laser energy. For this reason, selecting a specific laser depends on the target tissue the practitioner wishes to treat.
4. The primary effect of a laser within target tissue is photothermal.
   - -When the target tissue containing water is raised above 100 degrees centigrade, vaporization of the water occurs, resulting in soft tissue ablation.
   - -Since soft tissue is made up of a high percentage of water, excision of soft tissue initiates at this temperature. Hard tissue composed of hydroxyapatite crystals and minerals are not ablated at this temperature, but the water component is vaporized, the resulting steam expands and then disperses the encompassing material into small particles.

Question 138

How are lasers classified?

Answer 138

Lasers typically are classified by the active medium that is used to create the energy.

Question 139

What are the types of lasers used in dentistry and for what procedures are they used for?

Answer 139

1. CO2 laser - well absorbed by water, and therefore, effective in incising, excising and coagulating soft tissue.
   - -Primarily a soft tissue laser, as its wavelength is poorly absorbed by hydroxyapatite.
2. Diode laser - contains a solid active medium and is composed of semiconductor crystals of aluminum or iridium, gallium and arsenic.
   - -Effectively is absorbed by pigmented tissues and has a good depth of penetration.
   - -Relatively unable to be absorbed by hard tissue. For this reason, soft tissue surgery can be completed safely without affecting adjacent hard tissue structures.
3. Nd:YAG laser - consists of neodymium ions and crystal of yttrium, aluminum and garnet.
   - -This laser energy is absorbed well by pigmented tissues and only minimally absorbed by hard tissue. Soft tissue surgery can be completed adjacent to the tooth accurately and safely.
   - -Pigmented surface carious lesions can be removed without affecting healthy tooth structure.
   - -The Nd:YAG wavelengths are absorbed by hemoglobin and are effective in coagulation and hemostasis during soft tissue procedures.
4. Erbium lasers - consists of two separate wavelengths.
   - -The Er:YAG consists of erbium ions and a solid active medium of crystals of yttrium, aluminum and garnet.
   - -The Er, Cr:YSGG contains erbium, chromium ions, and a crystal of yttrium, scandium, gallium and garnet.
   - -In addition to facilitating soft tissue procedures, the erbium lasers effectively can remove caries and prepare enamel, dentin, cementum and bone.

Question 140

What diagnostic applications can lasers have in dentistry?

Answer 140

Laser fluorescence (LF) can be used as an additional tool combined with conventional methods for detection of occlusal caries.

• -The laser system can interpret the emitted fluorescence on the occlusal surface which correlates with the extent of demineralization in the tooth.
• -LF may be used as a complementary instrument when diagnosing occlusal caries in cases of questionable findings after visual inspection.
• -LF caries detection is not recommended under dental resins or sealants due to a high probability of unreliable readings as a result of the intrinsic fluorescence from the sealant material.

Question 141

What soft tissue clinical applications can lasers have in dentistry?

Answer 141

Clinical procedures include:

1. Maxillary and lingual frenectomies
2. Operculectomies
3. Exposure of teeth for orthodontic purposes
4. Gingival contouring/gingivectomies
5. Removal of mucosal lesions and biopsies
6. Treatment of aphthous ulcers and herpetic lesions

Question 142

What types of lasers are used in soft tissue clinical applications in dentistry?

Answer 142

1. CO2, diode and ND:YAG lasers all have the capability of effectively incising tissue, coagulating and contouring tissues.
2. Erbium lasers also have the capability of providing soft tissue procedures, however, the hemostatic ability of these wavelengths is not as effective as CO2, diode and ND:YAG wavelengths.

Question 143

What hard tissue clinical applications can lasers have in dentistry?

Answer 143

1. Removal of caries and preparation of teeth (Nd:YAG, Er:YAG adn Er,CR:YSGG lasers).
2. Indirect and direct pulp capping treatments.
3. Primary tooth pulpotomies and root canal disinfection.
   - -Success rates of laser pulpotomies have been comparable to those of formocresol pulpotomies.

Question 144

What types of lasers are used in hard tissue clinical applications in dentistry?

Answer 144

The erbium lasers are the predominant lasers used for hard tissue procedures.

Question 145

What are the benefits of using lasers in pediatric dentistry?

Answer 145

1. The selective and precise interaction with diseased tissues.
   - -Erbium lasers can remove caries effectively with minimal involvement of surrounding tooth structure bc caries-affected tissue has a higher water content than healthy tissue.
2. Less thermal necrosis of adjacent tissues is produced with lasers than with electrosurgical instruments.
3. Hemostasis during soft tissue procedures - no suturing may be required in most cases and wound healing can occur more rapidly with less post-operative discomfort and a reduced need for analgesics.
4. Little to no local anesthesia is required for most soft-tissue treatments.
   - -Nd:YAG and erbium lasers have been shown to have an analgesic effect on hard tissues, eliminating injections and the use of local anesthesia during tooth preparations.
5. Reduced operator chair time.
6. Decontaminating and bacteriocidal properties on tissues - requiring less prescribing of antibiotics post-operatively.
7. Provide relief from the pain and inflammation associated with aphthous ulcers and herpetic lesions without pharmacological intervention.
8. No vibratory effects of the conventional high-speed handpiece bc of non-contact of erbium lasers with hard tissue.

Question 146

What are the limitations/disadvantages of using lasers in pediatric dentistry?

Answer 146

1. Laser use requires additional training and education for the various clinical applications and types of lasers.
2. High start up costs are required to purchase the equipment, implement the technology and invest in the required education and training.
3. Most dental instruments are both side and end-cutting. When using lasers, modifications in clinical technique along with additional preparation with high-speed handpieces may be required to finish tooth preparations.
4. Wavelength-specific protective eye-wear should be provided and consistently worn at all times by the dental team, patient and other observers in attendance during laser use.
5. Vaporized aerosol may contain infection tissue particles. It is imperative that the doctor and auxiliaries adhere to infection control protocol and utilize high speed suction.
   - -The practitioner should exercise good clinical judgement when providing soft tissue treatment of viral lesions in immunocompromised patients; as the potential risk of disease transmission from laser-generated aerosol exists. To prevent viral transmission, palliative pharmacological therapies may be more acceptable and appropriate in this group of patients.

Question 147

What pain scales indicators can be used with children?

Answer 147

1. FACES pain scale
2. Wong-Baker FACES scale

–Pain experienced by children with special healthcare needs or developmental disabilities is more challenging to assess accurately and may require utilization of scales that rely on observations such as vocalization, facial expressions and body movements.

Question 148

What behavior and pharmacologic pain control therapies are available?

Answer 148

1. Behavior therapy includes:
   - -Guided imagery
   - -Distraction
   - -Play therapy
   - -Tell-show-do
2. Pharmacologic therapy includes:
   - -Adequate local anesthesia
   - -Anxiolysis
   - -Moderate sedation
   - -Deep sedation

Question 149

What percent of children undergoing full mouth dental rehabilitation experience post-operative pain?

Answer 149

95% of children undergoing full mouth dental rehabilitation, regardless of extent of treatment, report pain of moderate intensity.

• -Pain scores usually are their highest immediately postoperatively while the patient is in the post-anesthesia recovery unit.
• -Patients who had extractions, as well as those who had 12 or more dental procedures, were more likely to experience pain at home.

Question 150

When should analgesics be given after the procedure?

Answer 150

Analgesics should initially be administered on a regular time schedule if moderate to severe pain is considered likely during the first 36 to 48 hours and not “as needed” so as to create stable plasma levels of analgesics and decrease the chance of breakthrough pain.

Question 151

What type of analgesics are usually used for postoperative pain?

Answer 151

Since most cases of postoperative pain include an inflammatory component, NSAIDs, are considered first line agents in the treatment of acute mild to moderate postoperative pain.
–Acetaminophen lacks anti-inflammatory properties but can be a non-opioid alternative when NSAIDs are contraindicated.

Question 152

What are the precautions concerning acetaminophen?

Answer 152

Overdose of acetaminophen is a common pediatric emergency. For this reason, it must not be given prior to six hours after the last dose was administered, whether at home, in office, or in the post-anesthesia recovery unit of the hospital.

Question 153

What are the precautions concerning codeine?

Answer 153

–Codeine, one of the most widely prescribed narcotics, is a “prodrug” that is metabolized into morphine in the liver. Research has found a genetic polymorphism of the liver cytochrome enzyme which causes “ultra-rapid” metabolizers and “poor metabolizers” of codeine. There is no way to reliably identify which pt is a variant, other than a non-commercially available laboratory test.

1. Ultra-rapid metabolizers - convert codeine into high levels of morphine very quickly, which may cause undesirable consequences including death, in infants and children.
2. Poor metabolizers - under-respond to codeine. Repeated doses of codeine/acetaminophen combinations sooner than six hours in these pts may result in acetaminophen overdose.

Question 154

What are the effects of occupational exposure to ambient N2O?

Answer 154

1. Effects of occupational exposure to ambient N2O are uncertain, especially since the introduction of methods to scavenge N2O and ventilate operatories.
2. A maximum safe level of ambient N2O in the dental environment has not been determined.

Question 155

What is the AAPD recommendation for minimizing occupational exposure to N2O?

Answer 155

1. Use scavenging systems that remove N2O during pt’s exhalation.
2. Ensure that exhaust systems adequately vent scavenged air and gases to the outside of the building and away from fresh air intake vents.
3. Use, where possible, outdoor air for dental operatory ventilation.
4. Implement careful, regular inspection and maintenance of the nitrous oxide/oxygen delivery equipment.
5. Carefully consider pt selection criteria (i.e., indications and contraindications) prior to administering N2O.
6. Select a properly-fitted mask size for each pt.
7. During administration, visually monitor the pt and titrate the flow/percentage to the minimal effective dose of N2O.
8. Encourage pt to minimize talking and mouth breathing during N2O administration.
9. Use rubber dam and high volume dental evacuator when possible during N2O administration.
10. Administer 100% oxygen to the pt for at least 5 minutes after terminating nitrous oxide use to replace the N2O in the gas delivery system.

Question 156

What is the National Institute for Occupational Safety and Health (NIOSH) recommendation for nitrous?

Answer 156

NIOSH has recommended that the exhaust ventilation of N2O from the pt’s mask be maintained at an air flow rate of 45 L/min and vented outside the building away from fresh air intakes.

• -However, scavenging at this rate has been shown to reduce the level of psychosedation achieved with N2O inhalation.
• -Where possible, outdoor air should be used for dental operatory ventilation. Supply and exhaust vents should be well separated to allow good mixing and prevent “short-circuiting.”

Question 157

What patients should be managed by other behavior guidance techniques besides nitrous?

Answer 157

1. Patients who are unwilling or unable to tolerate the nasal hood.
2. Patients with medical conditions (e.g., obstructive respiratory diseases, emotional disturbances, drug dependencies) that contraindicate the use of N2O.

Question 158

What patient behaviors result in an increase in ambient N2O levels?

Answer 158

Talking, crying and moving have been shown to result in significant increases in baseline ambient N2O levels despite the use of the mask type scavenging systems.

Question 159

What is the pediatric dentist responsible for when deep sedation or general anesthesia is provided in a private pediatric dental office?

Answer 159

1. The pediatric dentist must be responsible for evaluating the educational and professional qualifications of the general anesthesia or deep sedation provider (if it is other than the pediatric dentist) and determining that the provider is in compliance with state rules and regulations associated with the provision of deep sedation and general anesthesia.
2. The pediatric dentist is also responsible for establishing a safe environment that complies with local, state and federal rules and regulations as well as the “Guideline for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures” for the protection of the patient.

Question 160

How have pediatric dentists experiences difficulty in hospitalization and operating room access?

Answer 160

Pediatric dentists occasionally have experienced difficulty in gaining an equal opportunity to schedule operating room time, postponement/delay of non-emergency dental care and economic credentialing.
–Economic credentialing (i.e., the use of economic criteria not related to quality of care or professional competency) to determine qualifications for granting/renewing an individual’s clinical staff membership or privileges should be opposed.

Question 161

How can the pediatric dentist contribute as members of the hospital staff?

Answer 161

1. Provide comprehensive dental services to pts within an operating room setting.
2. Provide consultative and emergency services - “Team” (e.g., cleft lip/palate, hemophilia) evaluations of pts often require dental input and certain medical protocols (e.g., hematopoietic cell transplantation) require an oral examination.
3. Participate within the hospital’s organizational structure through committee memberships of either clinical or administrative purpose.

Question 162

After the credentialing process for hospital staff membership, what responsibilities must a pediatric dentist accept and fulfill?

Answer 162

1. Patient care within the limits of approved clinical privileges.
2. Possible participation in emergency department on-call rotations.
3. Timely completion of medical records.
4. Compliance with the rules and regulations of the medical/dental staff and the policies and procedures of the hospital.

Question 163

Who do you discuss the oral hygiene counseling with?

Answer 163

1. Up to 2 years old - Parent
2. 2 to 12 years old - Patient and parent
3. Over 12 years old - Patient

Question 164

At what age do you begin to discuss substance abuse counseling and intraoral/perioral piercing counseling?

Answer 164

Begin at 6 years old.

Question 165

Why is capping of non-covered services by third party insurance companies contrary to the public interest?

Answer 165

1. Larger dental benefit carriers with greater market share and more negotiating power are favored in this arrangement. Dentists typically may refuse to contract with smaller plans making this requirement, while unable to make the same decision with larger plans controlling greater competition among dental plans. If smaller plans and insurers are unable to survive, the group purchaser and subscriber are ultimately left with less market choice and potentially higher insurance cost.
2. It is unreasonable to allow plans to set fees for services in which they have no financial liability, and which may not cover the overhead expense of the services being provided. When this provision precludes dentist participation in a reimbursement plan, subscribers realize less choice in their selection of available providers. In many cases, especially in rural or other areas with limited general or specialty practitioners, this adversely affects access to care. This is particularly true for vulnerable populations, including children with special health care needs.
3. For dentists forced to accept this provision, the artificial pricing of uncovered services results in cost-shifting from those covered under a particular plan to uncovered patients. Thus, the uninsured and those covered under traditional indemnity or other plans will shoulder the costs of these provisions. Capping of non-covered services is not cost saving; it is cost-shifting - often to those least able to afford healthcare.

Question 166

What is a recovery audit contractor (RAC)?

Answer 166

A private entity that reviews paid claims and, in some cases, earns contingency fees for improper payments it retrieves.

Question 167

How can you prepare for an external audit?

Answer 167

The AAPD encourages its members to develop internal self-audit programs to address these challenges.

• -Internal audits are used in order to preemptively detect discrepancies before the external authorities can discover them and impose penalties.
• -A compliance program generally will incorporate a credible internal audit system, which means that it must be prepared to respond to an external audit by various authorities.

Question 168

What is the AAPD’s position on recovery audit contractors (RACs)

Answer 168

1. The AAPD strongly believes that, while audits are a part of third party payment contracts and are necessary to protect the integrity of these programs, such audits must be completed by those who have credentials on par with the dental provider being audited.
2. The AAPD is adamantly opposed to auditors receiving financial incentives for any money recuperated through these audits. This represents a conflict of interest.

Question 169

What is the AAPD’s position on provider profiling?

Answer 169

The AAPD opposes provider profiling and believes that the dentist providers selected for audits should be chosen randomly or with compelling evidence that makes them an outlier as compared to their peers who practice in similar geographic areas, on similar populations of patients, and within the same specialty.

Question 170

How can peer review be a part of an audit otucome?

Answer 170

The AAPD supports peer review in lieu of financial penalties when an audit shows that no intent to fraud was present, as a way to offer information and support to dentists who need to re-acquaint themselves on best practices regarding chart documentation, coding and billing practices relating to third party payors.
–The intent of peer review is to resolve discrepancies between the dentists and third party payors expeditiously, fairly and in a confidential manner.

Question 171

When should transition planning begin for transitioning a patient with special health care needs from a pediatric-centered to an adult-centered dental home?

Answer 171

There is agreement in the literature that specific transition planning should begin between the ages of 14 and 16 years old.

Question 172

What percent of general dentists vs pediatric dentists treat patients with special health care needs?

Answer 172

1. Only 10% of general dentists treat pts with special health care needs often or very often. 70% of general dentists rarely or never treat pts with special health care needs.
2. 95% of pediatric dentists routinely treat pts with special health care needs.

Question 173

What are the barriers to care for adults with special health care needs?

Answer 173

1. Lack of trained providers - lack of general dentists and specialists willing to accept these pts.
2. Lack of integration between medical and dental homes. The most efficient but least common arrangement is a single institution having providers from both disciplines (typically a hospital or regional care center). Transitioning may become less of an issue in these facilities, however, those with comprehensive dental clinics are limits in number and spread unevenly across the country.

Question 174

What are the commonly accepted virtues of ethics?

Answer 174

1. Autonomy - reflects the patient’s or, if the patient is a minor, the parent’s or guardian’s right to be involved in treatment decisions. The caregiver must be informed of the problem and that treatment is recommended.
2. Beneficence - indicates the dentist has the obligation to act for the benefit of the patient in a timely manner, even when there may be conflicts with the dentist’s personal self interests.
3. Nonmaleficence - dictates that the dentist’s care does not result in harm to the patient. In situations where a dentist is not able to meet the patient’s needs, referral to a practitioner capable of providing the needed care is indicated.
4. Justice - expresses that the dentist should deal fairly with patients, colleagues and the public.

Question 175

When is a second opinion required?

Answer 175

Second opinion is recommended if:

1. The pt disagrees with or questions the diagnosis or the treatment plan of the health care provider.
2. The pt has multiple medical problems or is diagnosed with a life-threatening disease such as cancer.
3. There is no improvement in the pt’s condition.
4. There is a communication barrier between the pt and the provider.
5. There is extensive oral care needs or high cost may make treatment prohibitive.

Second opinion may be warranted if:

1. Healthcare practitioner is unsure of the diagnosis or diagnosis/treatment is beyond the scope of their expertise.
2. Required by a third payor.

Question 176

What are the advantages and disadvantages of a “blind” second opinion?

Answer 176

Blind second opinion - when medical/dental records, test results and first provider’s opinion are not made available to the second provider.

Advantages of blind second opinion:
1. It cannot be influenced by previous information. The provider will develop his/her own unbiased opinion.

Disadvantages of blind second opinion:

1. The provider performing the second opinion may have to repeat diagnostic tests and the pt will incur additional costs.
   - -An option could be to provide test results, radiographs and other information without the first doctor’s written diagnosis and treatment recommendations. This would allow for an unbiased opinion without having the pt incur unnecessary charges or radiation exposure from repeated radiographs.
2. The second provider may not be able to explain to the pt why his/her opinion is different without knowing the pt’s previous history and the basis of the first provider’s opinion.

Question 177

What are the legal implications of requests for second opinions?

Answer 177

1. Health care providers rendering second opinions could be unwarily involved in litigation, either on behalf of the pt or in defending themselves against other practitioners, as a result of the consult.
2. The fact that one is the second or third professional consult does not mean that the provider is exempt from liability.
   - -A dissatisfied pt could file a lawsuit naming not only the treating doctor, but also the doctor rendering the second opinion as defendants.
   - -A colleague who believes his or her professional reputation has been damaged by statements made to a pt during a consultation could file a lawsuit for defamation of character. Pts should be advised of their health status without disparaging comments about their prior treatment or previous provider.

Question 178

What are the second opinion rights?

Answer 178

1. A patient has a right to a second opinion. A provider who is trained and experienced in diagnosing and treating the condition should provide the second opinion. Internet sites or a telephone conversation cannot be relied upon and should not constitute a second opinion.
2. A health care practitioner has the right to request a second opinion from one or multiple practitioners/specialists as deemed necessary to facilitate the optimal clinical outcome.

Question 179

What is the goal of the second opinion?

Answer 179

1. The goal of a second opinion consultation should be to educate the pt regarding the diagnosis and available treatment options, including their risks and benefits.
2. Health care providers may disagree on the best treatment for an individual pt.
   - -Instances of gross or continual faulty diagnosis or treatment by other providers may require that the provider be reported to an appropriate reviewing agency as determined by the local component or constituent dental society.

Question 180

Are second opinions mandatory?

Answer 180

1. Most second opinions are voluntary. It is the responsibility of the pt to check with his/her insurance carrier for specific policies and benefits regarding coverage of second opinions.
2. Second opinions may be mandatory by third party payors. The provider should be independent and the opinion should be based on best outcomes for the pt and not financial incentives.

Question 181

Dental stem cells are what type of stem cells?

Answer 181

Dental stem cells are a subset of adult mesenchymal stem cells, which are highly proliferative and have the ability to differentiate into many cell lines.

Question 182

What are the suggested stem cell therapy applications related to oral health care?

Answer 182

Suggested applications related to oral health care have included:

1. Wound healing
2. Regeneration of dental and periodontal tissues
3. Regeneration of craniofacial structures (e.g., repair of cleft lip/palate)

Question 183

What dental structures may serve as a source of stem cells?

Answer 183

Pulpal tissue of exfoliating primary teeth and surgically removed third molars may serve as a source of mesenchymal stem cells.
–The public is increasingly aware of this emerging science, and more parents are expressing interest in harvesting/banking dental stem cells?