Lecture 1 Flashcards
medically compromised patient
any patient with any pre-existing conditions that may probably complicate treatment
Thorough medical evaluation and risk assessment will:
• improve patient safety by preventing and reducing emergency situations
• improve their treatment outcomes
• facilitate early detection and prevention
• make sure that patient treatment is individualized and equitable.
Common health conditions that can be caused by systemic health and affect oral health, or are caused by oral health and affect systemic health and affect dental management (10)
• Diabetes
• HTN
• Immunocompromised
• Allergies
• Pregnancy
• Asthma
• Heart conditions
• Respiratory conditions
• Cancer
• Alzheimer’s disease
How is comprehensive patient medical evaluation accomplished?
Gather a detailed medical history, obtain vital signs, medical consults where indicated
During the assessment portion of the process of care, we need to assess the patient to see if they are a risk for treatment. A patient’s risk is rated low, moderate or high based on:
- their health
◦ ASA score (high ASA=higher risk), 2. 2. Oral and systemic conditions ( more systemic or uncontrolled systemic conditions or oral conditions= more complicated tx= higher risk)
how complicated/extensive their tx - compliance and understanding for tx ( basically, if the patient does not understand their treatment, or isn’t compliant to their treatment, it may increase a risk for complications in the chair).
Why do patients with special needs show poorer oral health?
They are underserved
People who have some sort of special needs may not be get quality tx because
either a barrier on their end in finding and affording care or a barrier on the clinician end with either not wanting to serve them or being unfamiliar or not trained on how to help them.
Barriers on the clinician end can be reduced by
Feeling more comfortable treating these patients, treat more of these patients, show greater future intention to treat these patients
Normalization
Provide people with disabilities the same conditions and experiences as those without disabilities; making sure that people with special needs have access to care and receive it in a way thats as close to mainstream as possible
How can we evaluate if a patient is a special needs patient? How do we move forward with these patients?
Evaluate if they can comply with OHI recommendations, if they have a special need complicates ability to provide care and figure out what alternatives to OHI and care need to be made
How can we tailor treatment before, during and after treatment to prevent and be prepared for emergencies?
• Before: plan out appt time and determine if patient needs premed (prosthetic heart valve, recent heart valve surgery, infective endocarditis, congenital heart defects etc.)
• During: less chair time=less risk for emergency, less stress and pain=less risk of emergency, less invasive procedure= less risk of emergency
• After: Collaborate with primary health care providers to coordinate follow up care
Most common chronic illness in children
Caries
stats of children ages with caries
In primary teeth ages 2-5: 21%; In permanent teeth of children 6-11: 51%; 12-19 adolescents: 54%
Severe consequences of children with caries that have not received treatment
can cause infection, pain, caries in permanent teeth, missing school, not being able to focus at school/ low grades, expensive dental work, not being able to chew properly, difficulty sleeping, poor self esteem
Early childhood caries
A common type of caries that occurs in young children
Etiology of early childhood caries (6)
• Low socioeconomic status (can’t afford healthy food)
• feeding ( high sugar intake)/ diet
• Eating time intervals and type of food
• lack of dental care/ no dental home
• no fluoride use
• history of caries in family/ genetics
In early childhood caries, which teeth are first affected?
more common at incisors because of lack of saliva and eventually progress posterior
Why are most incidences of childhood caries undiagnosed?
Parents or caregivers do not seek dental care at an early age
Who plays a major role n preventing caries and initiating early treatment?
Clinicians
What is the etilogy triad for caries?
Bacteria, teeth and sugars
Etiology of caries: Its a multi factorial process caused by what factors?
environmental, behavioral, and host risk factors
Describe the process of how caries form
• Oral bacteria (including mutans streptococci and lactobacilli) metabolize dietary carbohydrates into acids
• Acid demineralizes tooth enamel
• If the cycle of acid production and demineralization continues, the enamel will become weakened and break down into a cavity
Cariogenic
Producing or promoting the development of tooth decay
Etiology of caries: sugars
A. Insufficient time for demineralization process: After eating, bacteria in mouth produce acid that persists for 20-40 min, lowering the mouths normal ph in danger zone. After 40 mins, remineralization occurs when the acid is buffered by saliva.
If sugars are consumed frequently, there is insufficient time for the remineralization process to occur; The tooth is subjected to continued demineralization and the caries process progresses. If sugars are consumed infrequently, teeth are able to fully remineralize and the caries process halts.
Any tooth surface can develop a cavity, but some surfaces are more prone like?
• Newly erupted teeth (due to immature enamel)
• Teeth with developmental defects
Difference between general dentists and pediatric dentists
• Both trained to take care of oral health
• Pediatric dentist brings specialized skills and knowledge designed specifically for children
• 2 to 3 year pediatric residency, includes education on:
• Child psychology
• Growth and development
• Pediatric patient management techniques
• Child-focused approach
• Specialized equipment
• Behavior management techniques
• Oftentimes a fun and inviting environment for kids!
Caries risk assessment
Is a tool used to determine a patient’s risk of developing dental caries.
A CRA categorizes a patient’s risk for caries by using their medical hx, dental hx, clinical conditions (i.e existing caries, plaque etc.) and psychosocial history (diet, oral home care) .
Helps clinician identify modifiable and non-modifiable risk factors and provides recommendations and education to reduce caries risk.
Treatment is determined based on risk level. Clinician needs to use their own judgement. Always explain and educate pt on findings and discuss preventative strategies based on individual need.
◦ Low- 0; Moderate- 1-9; High- higher than 10; or one high risk factor (worth 10 points)
2 forms: Patients 0-6 and patient 6 and up
CAMBRA
Evidence-based approach to preventing and managing cavities at the earliest stages
It focuses on evaluating a patient’s individual risk factors for developing dental caries and creates a personalized treatment plan based on risks, rather than just treating existing cavities
• Involves assessing several factors to determine a patient’s susceptibility to cavities:
• Diet
• Oral hygiene habits
• Saliva flow
• Fluoride use
Common oral health risk factors for children and adolescents
Common oral health risk factors for children and adolescents include:
Dietary Habits
• High sugar consumption (sugary drinks, candy, processed foods)
• Frequent snacking between meals
• Prolonged use of sippy cups with liquids other than water
Oral Hygiene Practices
• Inadequate brushing and flossing techniques
• Not using fluoride toothpaste
Socioeconomic Factors¥
• Lower socioeconomic status
• Limited access to dental care
Genetics and Family History
• Predisposition to tooth decay based on family history
Other Factors
• Certain medical conditions (dry mouth, developmental disabilities)
• Poor nutrition and vitamin deficiencies
• Lack of a “Dental Home”
Having a dental home is important to
establish a trusting and ongoing care between provider and patient.
Barriers to finding dental care for children
• financial
• parent low dental literacy
• dental care not accessible
• language (parent and dentist do not speak same language; do not ask child (patient) to translate)
Objectives when treating pediatric patients
Children need to learn the importance of profession dental care and should be taught how to have good dental habits.
Visits should be focused on establishing rapport and trust, establishing positive oral habits and providing any other appropriate education , providing preventative therapy, and maintaining rapport thru lifespan.
May need interventions like nutrition counseling, home care instruction, help establish habits, and safety practices.
Anticipatory guidance for children meaning
Educating parents in advance about developmental milestones, how to manage child’s oral health at each stage and also potential oral issues and their preventative measures.
AG for infant
Growth and development
• Teething
• Discomfort
• Use of pain meds
• Safe teething rings
• No benzocaine products - risk of methemoglobinemia
• Irritability
• Low-grade fever
• Excessive salivation
• Maternal oral health is associated with infant oral health
ОНІ
• Rice grain-size toothpaste
• Soft bristled brush
• Brush BID
• Check the appearance of teeth and gums
• Lift upper lip to check for signs of decay
• Establish dental home and come in for periodic exams
• Discuss frequency
Nutrition
• Breastfeeding can aid in dental caries prevention
• Discourage milk/formula use in bottle at night
• Bottle nipple shape important with oral development
• Avoid testing temperature of food with mouth, sharing utensils, or orally cleaning off bottle nipples
• Helps prevent transmission of bacteria from the parent
• Introduce a small cup when infant can sit up unassisted
• Wean from a bottle by 12 months
• Avoid introducing sugar until 2 years of age
• No 100% fruit juice before 12 months
• Limit to 4 oz/day from 1-3 years of age
Trauma/Injury prevention
• Awareness that injuries to the head, face, and mouth are common among infants
• Never attempt to reinsert an avulsed baby tooth
Non-nutritive sucking
• Common habits
• Pacifier
• Thumb-sucking
• Finger sucking
• Should be limited to prevent:
• Open bite
• Crossbite
• Narrow arch
• Speech impediments
Common oral conditions in infants
Ankloglossia
• Short lingual frenum that can cause speech hindrance, feeding, and tongue movement. Needs surgical correction
Candidiasis
• White patch with inflamed underlying surface, white can wipe off, can apply Nystatin, in health will go away on it own
Primary herpetic gingivostomatitis
• Viral infection in mouth cause by HSV-1; usually latent but sometimes occurs in chilren at first exposure
◦ Gingiva will be red
◦ Mucousa will show hemorrhages
◦ Painful vesicles around oral cavity
◦ Fever
◦ Malaise (general feeling of discomfort)
◦ Lymphadenopathy
◦ Difficulty eating in
◦2 week duration
◦ Push fluids and can use pain meds
◦ Should heal without scars
Common oral conditions in school aged children
Primary herpetic gingivostomatitis
• Viral infection in mouth cause by HSV-1; usually latent but sometimes occurs in chilren at first exposure
◦ Gingiva will be red
◦ Mucousa will show hemorrhages
◦ Painful vesicles around oral cavity
◦ Fever
◦ Malaise (general feeling of discomfort)
◦ Lymphadenopathy
◦ Difficulty eating in drinking
◦ 2 week duration
◦ Push fluids and can use pain meds
◦ Should heal without scars
AG for school aged children
Parent education
Growth and development
• Changes in the teeth and mouth
• Orthodontic needs
Caries risk/prevention
• Sealants, fluoride
• ОНІ
Nutrition
Trauma/Injury prevention
• Sports-related
• Avulsed tooth
Non-nutritive sucking habits
AG for adolescents
Parent/patient education
Growth and development
• Changes in the teeth and mouth
• Orthodontic needs
Caries risk/prevention
OHI/fluoride use
• Oral malodor
Nutrition
• Eating disorders
• Frequency increases due to growth & development
• Highest caries risk for males
Trauma/Injury prevention
• Sports-related
• Piercings
Oral manifestations of STI
• HPV vaccine status
Use of tobacco and other substances
Toddlers patient management (1-3)
• Make sure to consider, evaluate and monitor eruption
• Use child-friendly terms (reduces stress and anxiety)
• Conduct thorough oral and physical exam (look out for signs of abuse; report)
• Tell/show/do
Preschoolers (3-5) management
• Happy visit
• Child friendly verbiage
• Modify chair; can remove headrest
• Preferable that parent is not present
School-aged children (6-11) management
• Allow for more patient participation in appointments
• Ask parent to remain in reception area
• Consider challenged of mixed dentition
• Assess periodontium
• Increase patient responsibility with home care habits
• Ensure the patient can brush and floss properly
• tell/show/do
• Less parental supervision with decision making (food, safety, habits) - provide nutritional, safety and OHI guidance
• Positive communication - highlight successes
Adolescents (11-18) management
• Permanent dentition - help patient understand that oral health habits affect teeth throughout lifetime
• Lots of physical & psychological changes are taking place
• Appearance is important - use it as a motivator for increased home care
• Assess periodontium
• Address tobacco & other substance use
• Vaping is widely used; marketed to teens; falsely believed to be safe
• Anxiety - family, school, peer pressure, may lead to violence and/or substance use/abuse
• Intimate partner violence is a consideration - look for signs (physical & emotional)
Periodontal risk assessment for children and adolescents
• Childhood inflammation may advance to periodontal disease resulting in tooth loss
• Early identification and prevention strategies should be central to the dental hygiene visit
• Change in periodontium with shedding/eruption should be considered
• Assess clinically and use radiographs to determine periodontal status
• PSR may be used to screen for disease
• Adolescents have increased risk for periodontal infections due to hormonal changes/more independence/less supervision
• Emphasize prevention during assessment and use motivational language to encourage compliance
• Biofilm-induced gingivitis is most common among children and appears to be more severe in adolescence due to hormonal changes
Documentation after a pediatric appt
Make sure documentation includes assessment info including risk assessments, any pathologies, OH status, remember this is pediatric so anticipatory guidance is necessary and needs to be documented, completed interventions, child’s behavior or temperament during appt, next appt Interval and rationale
Documentation after a pediatric appt
Referral, Planning, & Documentation
• Provide referral for conditions requiring intervention by other providers
• Care plan is based on dental hygiene diagnosis, risk factors present, and patient concerns-inform parent and patient; obtain consent after asking questions
• Documentation:
• Overall appraisal
• Pathology
• OH status and risk assessment (caries/perio)
• Anticipatory guidance provided
• Interventions completed
• Behavior/temperament
• Next visit interval and rationale
What ASA patients are safe treat in general practice with minor or no modifications?
ASA 1 and 2
What ASA patients require more substantial changes to their management and potentially referral to a hospital setting?
ASA 3 and 4
Elective treatment should be avoided on ASA___ patients.
ASA 4
Two main types of cariogenic bacteria
streptococcus mutans and lactobacillus
Cariogenic bacteria can be transferred in what two ways
• Vertical transmission from the primary caregiver, most often the mother, via saliva contact
• Horizontal transmission from family members and care providers, such as in school and daycare settings
What ensures that cariogenic bacteria is spread from caregiver to child?
The higher the bacteria level in the caregiver’s mouth, the more likely the child will become colonized with mutans streptococci
Caregivers with high bacteria levels usually have:
• High frequency of sugar intake
• Poor oral hygiene
• High levels of dental caries
Evidence supports that caregivers can decrease their risk of passing on cariogenic bacteria to their children by
decreasing their own caries levels
Caregivers can optimize their oral health and that of their children by:
• Receiving regular comprehensive dental care
• Limiting frequency of sugar in the diet
• Maintaining excellent oral hygiene and using fluoride toothpaste
• Using preventive agents such as: Topical fluorides, Antibacterial mouth rinses, Xylitol containing gums
How do systemic insults produce teeth with developmental defects?
The cells that manufacture enamel are very sensitive to systemic insults. So when systemic insults happen it causes the ameloblasts to halt enamel production . This will result in a microscopic or macroscopic defects.
___percent of children have developmental defects of enamel
20-40%
Enamel Defects may appear as changes in
translucency, color, or texture
In children, Enamel defects are associated with substantially increased risk of__
ECC
Signs of abuse in children and adolescents
Dental neglect
• A specific form of maltreatment, involves the willful failure of a parent or guardian to seek or follow through with necessary dental care for a child
Physical abuse
• Craniofacial, head, face, and neck injuries occur in more than half of child abuse cases
• Recognition of these injuries is critical in preventing further harm
Sexual abuse
• Oral manifestations of STIs
• Unexplained petechiae on hard palate can be a sign of sexual abuse
Psychological/Emotional abuse
• Extreme lack of self-esteem
• Significant, unexplained delays in development
• Inappropriate or underdeveloped social skills and poor personal boundaries
Treatment for children and adolescents
• Remove deposits and stain
• Educate parent/patient about biofilm control, caries prevention, nutrition, relationship between biofilm control and oral disease
• Use disclosing agent as a good visual to show the patient and/or parent location of biofilm and how it is removed
• Cautioned use of power scalers (remember that newly erupted teeth and primary teeth in general are less mineralized)
• Primary teeth may be hypersensitive
• Professional topical fluoride application - moderate caries risk
• Supplementation- if the patient has sub-optimal fluoride exposure, consider:
• Rinse
• Rx dentifrice
• Custom tray
