Prevention/Anticipatory Guidance Flashcards
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1
Q
What is the definition of perinatal period?
A
Period around the time of birth, beginning with completion of the 20 to 28th the week of gestation and ending 1 to 4 weeks after birth
2
Q
What percentage of S-ECC children have non-maternal MS streptococci genotypes?
A
74%
3
Q
What is the safest time to perform treatment on a pregnant female?
A
Second trimester 14th to 20th week
4
Q
Recommendations for perinatal oral health(geared at expectant mothers)
A
- Oral health education
- Oral hygiene
- periodontal infections can be a reservoir of inflammatory mediators like prostaglandin in GCF and blood
– associated with uterine contractions leading to preterm deliveries. However recent RCT did not support that treatment of perio dx during pregnancy prevents preterm birth, fetal growth restriction or preeclampsia.
- pregnant females may have n/v – recommend rinsing with a cup of water with 1 t. baking soda and waiting an hour before brushing to minimize erosion
- tb w/ fluoridated toothpaste, sugarfree or xylitol gum recommended
3. Diet discussion
4. Fluoride
– use fluoridated toothpaste and rinsing with alcohol-free, OTC mouthrinse with 0.05% NaF daily or 0.02% NaF twice a day
- Professional oral health care
– recalls, restoration of active caries to suppress/reduce maternal MS reservoirs and minimize transfer of MS to infant
- DELAY OF COLONIZATION is ultimate goal
- maternal MS levels are related significantly to MS colonization in plaque as well as dental caries in their children
5
Q
Ways to suppress maternal MS reservoirs include…
A
- dietary counseling, - reducing frequency of simple carb intake, - rinsing daily w/ CHX and fluoride starting 6th month of pregnancy, - removing and restoring active caries, - chewing xylitol-containing gum (at least 2x/day, demonstrated significant impact on mother-child transmission of MS and decreased child’s caries rate), - delaying MS transmission by avoiding behaviors that directly pass saliva to the child like sharing utensils or cups, cleaning dropped pacifier by mouth, etc. The higher the levels of maternal MS, the greater the risk of the infant being colonized. Maternal OH, perio disease, snack frequency, and SES also are associated with infant colonization.
6
Q
When does MS colonization of an infant occur
A
Birth Significant colonization occurs after dental eruption as teeth provide non-shedding surfaces for adherence.
7
Q
T/F Furrows of the infant’s tongue appear to be an important ecological niche for early colonization by S. Mutans
A
T.
8
Q
In contrast to declining prevalence of dental caries among children in OLDER age groups, the prevalence of caries in poor US children under the age of 5 is (increasing/decreasing).
A
Increasing
9
Q
Caries rate is declining, yet remains highest during what period?
A
Adolescence immature permanent tooth enamel, a total increase in susceptible tooth surfaces, environmental factors (diet, independence to seek care or avoid it, low priority for OH) and additional social factors may contribute to an upward slope of caries during adolescence
10
Q
Every infant should receive an oral health risk assessment from his/her primary health care provider (or qualified health care professional) by ___ months of age.
A
Six
11
Q
Electric cord safety, childproofing and dentifrice use are discussed when?
A
12-24 months for anticipatory guidance
12
Q
When should parents encourage children to stop sucking habits?
A
3 yrs or younger 50% of kids with NNS habit will discontinue between 24-28 months of ageincidence of NNS is 10-15% at age 5
13
Q
By when should the decision to remove or retain third molars be made?
A
Before the middle of the third decade (<25 yo)Recommend removal when high probability of disease or pathology and/or the risks associated with early removal are less than the risks of later removal.
14
Q
Is there a difference in late lower incisor crowding with removal or retention of asymptomatic impacted third molars?
A
NO according to 2012 Cochrane review
15
Q
How old is an adolescent?
A
10 to 18
16
Q
What are some of the distinctive needs of an adolescent?
A
- Potentially high caries rate (inattention to OH and increased intake of cariogenic substances)
- Increased risk for traumatic injury and periodontal disease
- a tendency for poor nutritional habits
- an increased esthetic desire and awareness
- complexity of combined ortho and restorative care
- dental phobia
- potential use of tobacco, alcohol and other drugs
- pregnancy
- eating disorders
- unique social and psychological needs
17
Q
Systemic benefit of fluoride incorporation into developing enamel is not considered necessary past ___ years of age.
A
- but topical benefits can be obtained thru optimally-fluoridated water, professionally applied and prescribed compounds, and fluoride dentifrices
18
Q
Adolescents have a (higher/lower) prevalence of gingivitis than pre-pubertal children or adults.
A
Higher due to rise of sex hormones during adolescence → affects composition of the subgingival microflora
Other studies suggest circulating sex hormones may alter capillary permeability → increased fluid accumulation in the gingival tissues
19
Q
What is PYD?
A
Positive youth development
Treatment and mgt of the adolescent that takes into account the pt’s psychological and social needs. Suggests a strong interpersonal relationship between pt and dentist can be influential in improving adolescent oral health and transitioning patients to adult care. Thru PYD, dentist can promote healthy lifestyles, teach positive patterns of social interaction, and provide a safety net in times of need
20
Q
Perimyolysis – what is it and what causes it?
A
Severe enamel erosion of the lingual surfaces of the teeth caused by exposure to gastric acids (e.g. Bulimia, excessive vomiting)
Example of an oral problem associated with adolescent behaviors. Others include:oral manifestations of venereal dxs, effects of birth control or antibiotics on perio structures intraoral and perioral piercings, traumatic injury to teeth from sports
21
Q
What percent of adolescent females who give birth are from low income families?
A
83%
22
Q
FDA’s five categories of pregnancy drugs
A
A: human studies, evidence supporting their SAFE use
B: no evidence of risk to humans (animal studies show no risk to fetus but no human studies, OR animal studies show risk to fetus but human studies do not)
C: may be used with caution (aspirin) (no adequate animal or human studies have been conducted, or adverse fetal effects shown in animals but no human data available); potential benefits may justify the potential risk D and X: not intended for use during pregnancy
D: evidence of human fetal risk exists, but benefits outweigh risks in certain situations like life-threating disorders; e.g. TetracyclineX: proven fetal risks outweigh any possible benefit A and B considered acceptable for use during pregnancy
23
Q
What percentage of pregnant pts experience Xerostomia?
A
44%
24
Q
When do signs of gingivitis occur in pregnancy
A
Second trimester and peak in the eighth month of pregnancy (THIRD trimester) with anterior teeth affected more than posterior teeth
25
Why are pregnant women at increased risk for aspiration during the last trimester
Pregnant women are considered to have a full stomach due to delayed gastric emptying and therefore are at increased risk for aspiration
26
When is dental prophylaxis supposed to occur during pregnancy
First trimester and again during the third trimester (if oral home care is inadequate or periodontal conditions warrant professional care)
27
Why is removal of amalgam restorations problematic during pregnancy
Mercury vapor released during the removal or replacement of amalgam restorations maybe inhaled and absorbed into the bloodstream and does cross the placental barrier the use of rubber dam and high-speed suction can reduce the risk of vapor inhalation also avoid using whitening products w/ existing amalgams as these products can release inorganic mercury from dental amalgams
28
Women who smoke during pregnancy have increased risk for…
Ectopic pregnancyspontaneous abortionpreterm deliveryincreased likelihood for infant having low birth weight Maternal tobacco use is also associated with intellectual disability and birth defects such as oral clefts, and the risk for perinatal mortality and SIDS is increased for infants of women who smoke.
29
Amount of radiation exposure from dental xrays
0. 038 millisieverts (mSv) for BWX
0. 15 mSv for FMX
30
Most sensitive organ to radiation-induced tumors both benign and malignant is…
Thyroid?
31
Avoid use of these drugs in the pregnant patient:
Aspirin and aspirin-containing products
erythromycin estolate
tetracycline
NSAIDs – not recommended either if necessary, administration should be avoided during the first and third trimesters, and limited to 48-72 hours use
32
Recommendations by age for pediatric oral health assessment, preventive services and anticipatory guidance/counseling
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33
T/F Oral hygiene counseling involves the patient and the parent.
T/F Oral hygiene is the responsibility of the parent.
T. T.
When a child demonstrates the understanding and ability to perform personal hygiene techniques, the health care professional should counsel the child
At age 12 and up, OHI geared toward patient only
34
Thumb/finger habits are considered normal until what age?
\<3 yo
Level of effect depends on duration \> magnitude \> frequency
35
CARIES RISK ASSESSMENT
the determination of the likelihood of the incidence of caries during a certain time period or the likelihood that there will be a change in the size or activity of lesions already present
36
T/F:
Currently, there are no caries-risk factors or combinations of factors that have achieved high levels of both positive and negative predictive values.
True
The best tool to predict future caries is past caries experience. Not useful in young children due to importance of determining caries risk BEFORE the disease is manifest.
37
Children with immigrant backgrounds have what times higher Caries rate than non immigrant children ?
Three times
38
What are the components of the caries risk assessment for 0-5yrs?
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39
What are the components of the caries risk assessment for \>/=6yrs
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40
A child having SHCNs and being a recent immigrant places them in which risk category?
Moderate risk for the Dental providers CRA
High risk for the Non-dental providers CRA ![]()
41
What is “active surveillance” of caries?
Active surveillance (Prevention therapies and close monitoring) of enamel lesions is based on the concept that txof disease may only be necessary if there is disease progression, that caries progression has diminished over recent decades, and that the majority of proximal lesions, even in dentin, are not cavitated.
42
What are the 3 moderate risk factors for 0-3 and 0- 5yo
Special needs, recent immigrant, visible plaque on teeth
43
What are the moderate risk factors for \>6 yo?
Special needs, recent immigrant, defective restorations, pt wearing an intraoral appliance
44
What are the 4 high risk biological factors for pts 0-5 yo?
Low socioeconomic,
parent has active cavities,
child has greater than 3 sugary snacks/beverages day,
put to bed with bottle containing natural or added sugar
45
What three clinical findings are associated with high caries risk in 0-5 year olds (according to the CRA for dental providers)?
\>1 dmf surfaces
active white spot lesions or enamel defects
elevated strep mutants levels
plaque on teeth → moderate risk
BUT on the non dental provider CRA – plaque, visible cavities/fillings, white spots are the three high risk clinical findings in 0-3 y.o.
46
What are the two Biological high risk factors for kids \>6 yo?
Low socioeconomic status
greater than 3 sugary snacks/beverages between meals
47
What are the 3 clinical findings for kids \>6 yo indicating high risk?
One or more interproximal lesions,
active white spot lesions/enamel defects,
low salivary flow
48
Caries Management Protocol 1-2 y/o
1-2 y.o.
Recall frequency
low: q6-12mo, mod: q6mo, high: q3mo
Fluoride
low: none, mod: q6mo professional topical tx, high: q3mo
(consider fluoride supplements when parent engaged and mod or high risk)
Diet
Counseling for all three risk groups
Limited expectations when parent not engaged
Restorative:
low: surveillance
mod: active surveillance of incipient lesions
high: active surveillance of incipient lesions, restore cavitated lesions with ITR or definitive restoration
49
Caries Management Protocol 3-5 y/o
3-5 y.o.
Recall frequency
low: q6-12mo, mod: q6mo, high: q3mo
Radiographs
low: q12-24mo, mod: q6-12mo, high: q6mo
Fluoride
low: tb with fluoride toothpaste bid,
mod: tb and q6mo professional topical tx,
high: brush with 0.5% fluoride (w/ caution), q3mo professional topical tx
(consider fluoride supplements when parent engaged and mod or high risk)
Diet
Counseling for mod and high risk (not low)
Limited expectations when parent not engaged
Sealants: All groups
Restorative
low: surveillance
mod: active surveillance of incipient lesions, restore cavitated or enlarging lesions
high: active surveillance of incipient lesions (if parent engaged), restore cavitated or enlarging lesions (and incipient if parent not engaged)
50
Caries Management Protocol
≥6 y.o.
Recall frequency
low: q6-12mo, mod: q6mo, high: q3mo
Radiographs
low: q12-24mo, mod: q6-12mo, high: q6mo
Fluoride
low: tb with fluoride toothpaste bid,
mod: tb and q6mo professional topical tx,
high: brush with 0.5% fluoride, q3mo professional topical tx
(consider fluoride supplements when patient/parent engaged and mod or high risk)
Diet
Counseling for mod and high risk (not low)
Limited expectations when parent not engaged
High risk: Xylitol counseling, whether or not pt/parent engaged
Sealants: All groups
Restorative
low: surveillance
mod: active surveillance of incipient lesions, restore cavitated or enlarging lesions
high: active surveillance of incipient lesions (if parent engaged), restore cavitated or enlarging lesions (and incipient if pt/parent not engaged)
51
EARLY CHILDHOOD CARIES DEFINITION
1 or more DMF tooth surfaces in any primary tooth in a child
under the age of six
D = decayed (cavitated or noncavitated)
M = missing (due to caries)
F = filled
52
SEVERE EARLY CHILDHOOD CARIES
definition
\< 3 yo – ANY SIGN of smooth surface caries
3 – 5 yo : 1 or more CMF smooth surface in primary max. anterior teeth
(1 or more Cavitated/Missing/Filled smooth surface)
age 3 : DMF ≥ 4
age 4 : DMF ≥ 5
age 5 : DMF ≥ 6
1 plus age!!!
53
ECC is largely untreated in children under the age of
Three
54
T/F:
Enamel defects are common in children with low birth weight, systemic illness, or under nutrition during the peri-natal period
True.
Women should be advised to optimize nutrition during their pregnancy and the infant’s first year, when enamel is undergoing maturation
55
Which two types of teeth are at higher risk of developing caries?
Newly erupted-bc of immature enamel, and hypoplastic
56
Caries-conducive dietary practices appear to be established by ____ months of age
12
by 12 months of age and are maintained throughout early childhood
57
How much juice per day for kids age 1-6?
No more than 4-6 oz. of fruit juice per day, from a cup (i.e. not a bottle or covered cup), and part of a meal or snack
58
Dental home establishment should be within ___ months of eruption of the first tooth and no later than ___ months of age
6, 12
to conduct a CRA and provide parental education including anticipatory guidance for prevention of oral diseases
Guideline: at the time of the eruption of the first tooth and no later than 12 months of age
59
Dietary guidelines
- Avoid sugar-containing beverages (e.g.juice, soda, sweet tea, milk w/ added sugar) in a baby bottle or no-spill training cup
- Infants should not be put to sleep with a bottle filled with milk or liquids containing sugars
60
When should parents be encouraged to have infants drink from a cup?
as they approach their first birthday
61
When should infants should be weaned from the bottle?
12-18 months of age
62
Ad libitum breast feeding should be avoided when?
After the first primary tooth begins to erupt and other dietary carbohydrates are introduced
63
T/F
Human breast milk is uniquely superior in providing the best possible nutrition to infants and has NOT been epidemiologically associated with caries
True.
But:
Breast feeding ≥ 7x/day after 12 mo. Of age IS associated with increased risk for ECC.
Ad libitum breast feeding after intro of other dietary carbs and inadequate OH are risk factors for ECC
64
T/F:
Frequent nighttime bottle feeding with milk is associatedwith, but not consistently implicated in ECC.
True
65
How much has obesity increased in the last 25yrs in the US?
Quadrupled in ages 6-11,
Doubled in ages 12-19
About 17% of children and adolescents between age 2-19 were obese (2007-8 study). Highest amongst Mexican-American boys
66
As teenage girls have increased their consumption of soft drinks what has happened?
Decrease in milk consumption by 40%, decrease in bone density, increased risk of osteoporosis
67
What is the estimated daily caloric need of a sedentary 4-6 year old girl?
1,200 Calories
1400 for active female
1400 for sedentary male, 2000 for active male 4 yo
68
What is the estimated range of Caloric need of a 2-3 yo?
1,000 → 1,400 (active)
69
What is the recommended servings of fruit, vegetables, grains, protein, milk for ~1600 calorie/day?
Fruits 1.5 cups
vegetables 2 cups
grains 5 oz
protein 5 oz
milk 3 cups
70
How is an “active” lifestyle different from a “sedentary” lifestyle?
Sedentary: light physical activity associated with typical life
Active: above + walking more than 3 miles per day at 3 to 4 mph
71
BMI calculation (metric)
kg weight ÷ m2 height
72
Overweight BMI-for-age\*
\*BMI-for-age used in children ages 2-19
BMI not applicable to children and teens due to amt of body fat changing with age and amt of body fat varying based on gender
≥ 85% BMI percentile
(BMI 25-29.9 for adults)
73
Obese BMI-for-age
≥ 95%
(BMI \>30 for adults)
74
Anorexia nervosa BMI-for-age
\< 5%
75
What % of US children are overweight?
20%
76
7 underlying conditions that cause obesity (not including medications)
- Prader-Willi
- Polycystic Ovarian Syndrome
- Cushing syndrome
- Down syndrome
- Growth hormone deficiency
- Pseudohypoparathyroidism
- Turner syndrome
77
Some drugs that cause obesity
- Glucocorticoids
- Phenothiazine
- Risperdone
- Lithium
- Gabapentin
- Amitriptyline
- Valproate
- Clonidine
Risperdone = antipsychotic; helps with children with autism (beh issues), schizophrenia, and bipolar disorder
Valproate = used to treat epilepsy and bipolar disorder \*can cause dry mouth
78
Is there an association between obesity and dental caries?
… 2006 Kantovitiz et al systematic review found only one study that showed correlation
79
What % of kids have caries by age 5?
60% - study by Crall
Then 78% of children by age 17 (NIH study 2003)
(68% in another study)
80
What percentage of children have caries by age 17?
68%
81
When should referral by PCPs to pedo occur?
As early as 6 mo, 6 mo after 1st tooth erupts, no later than 12 mo
82
80% of tooth decay is found in what % of children?
20-25%
83
What % of kids have caries by kindergarten?
40%
84
What amount of preschool age children receives care in a child care center?
1 out of 3
85
What % of kids 0-6 are in child care?
61%
86
What % of kids age 2-5 have ECC?
28%
87
ECC is ___ times more likely to occur in infants who are of low SES, who consume a diet high in sugar, and whose mothers have a low education level.
32 times
88
What percentage of low income children experience 75% of ECC
33%
89
How many days of school are missed from age 5-17?
3.1 days out of 100 students due to acute dental problems
90
Why does the AAPD oppose the practice of piercing intraoral and perioral tissues and use of jewelry on such tissues?
**Potential for pathological conditions and sequelae**
jewelry: may lead to increased plaque levels
gingival inflammation
gingival recession
caries
diminished articulation
metal allergy
piercings: associated with pain, infection
scar formation
tooth fractures
metal hypersensitivity rxns
localized perio dx
speech impediment
nerve damage
91
Under what circumstances does the AAPD support ITR?
- Restore and prevent progression of dental caries in young patients, uncooperative patients, patients with SHCN, situation where traditional restorative tx not feasible
- caries control in children with multiple carious lesions prior to definitive restoration of teeth
- in erupting molars when isolation conditions are not optimal for a definitive restoration
- patients with active lesions prior to treatment performed under GA
92
How is ART different from ITR?
ART endorsed by WHO and IADR is a means of restoring and preventing caries in populations that have little access to traditional dental care;
functions as definitive tx
93
T/F There is a marked increase of fluoride uptake and caries reduction after rubber cup prophy than toothbrush prophy.
False
There is no difference in caries rate or fluoride uptake
Plaque and pellicle are NOT a barrier to fluoride uptake in enamel.
94
What Amt of xylitol gives you diarrhea?
3-60g of xylitol per day
Common side effects are gas and osmotic diarrhea.
To minimize, introduce xylitol slowly over a week or more (to acclimate the body to the polyol).
95
What Amt of xylitol causes positive results (per studies)?
4-10g/day into 3-7 consumption periods
96
How much xylitol needed for clinical effect?
3-8g/day - not to exceed 8g/day,
minimum of two times/day
(per the AAPD Guideline on Xylitol Use)
97
Xylitol forms
**Syrup** (recommended for \<4 y.o.)
**chewing gum**
mints
**lozenges**
snack foods, gummy bears, milk not well-studied delivery vehicles.
mints and hard candies shown to be as effective as gum
AAP does not recommend use of chewing gum, mints, or hard candy by children _less than 4 years of age_ (choking risk)
Many commercially available products with xylitol (gum, mints, foods, nasal sprays, OH products) may not contain the necessary therapeutic level or xylitol as the only sweetener
98
What ways does xylitol affect strep mutans?
1. reduces plaque formation and MS adhesion to teeth (antimicrobial)
2. inhibits enamel demineralization via reducing acid production of MS (reduces virulence)
3. has a direct inhibitory effect on MS (disrupts energy production process of MS, leading to futile energy consumption cycle and cell death)
4. creates a MS mutant that sheds more easily into saliva, reducing the amount of MS in plaque
99
Xylitol works most effectively on teeth that are \_\_\_\_\_\_.
erupting
100
How much xylitol do you need to reduce strep mutans?
6.88 g/day
101
The amt (g) of xylitol intake per day that consistently is shown to reduce the incidence of caries or MS levels (and the dosage that the AAP recommends)
3-8 g/day at a frequency not less than 2x/day
102
CPP-ACP/recaldent has what ratio of Calcium:phosphate:fluoride?
Ca2+ : PO42- : F-
5 Ca: 3 Ph : 1 F
5:3:1
103
What is CPP-ACP and what is the common brand name?
Casein phosphoPeptide – Amorphous calcium phosphate
MI PASTE
104
How does MI paste work?
Inhibits demin, promotes remin of subsurface lesions
105
Sealants decrease restorative tx by what % over the next 3 yrs
72%
106
What's the success rate of sealants even after a decade?
80-90% - study by Feigal
107
What percentage of caries in school-age children occurs in pits and fissures?
As much as 90%
Also:
80-90% of permanent posterior teeth caries is pit/fissure
108
How long should primary enamel be etched?
15 seconds
109
What is the goal of mouth guards?
To reduce oral injuries, particularly to teeth and surrounding structures.
110
TOBACCO
kills what percentage of its users?
50%
111
Average age to start smoking
Age 11-12
112
Between 2004-2006 what types of tobacco use did not decrease amongst middle schoolers?
Smokeless tobacco, pipes, kreteks
Cigarettes, cigars, and bidis DID decrease in use
113
Among high schoolers from 04-06 did tobacco use increase, decrease or not change?
No change
114
What % of high schoolers and adults smoke?
HS- 20% (3.5 million)
Adults-19.8%
20%
115
What % of males and females use smokeless tobacco?
13.4% males, 2.3% females
leukoplakia in 50% of users within first 3 yrs
80% higher risk of developing oral cancer
60% higher risk of pancreatic and esophageal cancer
4x more likely to have root caries & perio
116
What risks does exposure to Environmental Tobacco Smoke/secondhand smoke increase (including two dental):
Secondhand smoke increases risk of
- SIDS
* *- respiratory infections
- middle ear infections**
- bronchitis
- pneumonia
* *- asthma**
- allergies
* *- Caries in primary dentition
- Enamel hypoplasia in both dentitions**
117
What are the two dental effects of second hand smoke?
Increased caries in primary dentition, increased enamel hypoplasia in primary and perm dentition
118
What % increased are cardio disease and lung cancer in nonsmokers who inhale secondhand smoke?
25-30%
In addition, infants and children exposed to smoke are at risk for SIDS, acute resp. infx, CEI, bronchitis, pneumonia, asthma, allergies, infections during infancy
119
What's 3rd hand smoke?
Particulate residual toxins deposited in layers over the home after a cigarette has been extinguished
Volatile compounds are deposited and “off gas” into the air over time
Children are most susceptible (dust ingestion rate in infants is \>2x that of adults). Associated cognitive defects in addition to the other associated risks of secondhand smoke exposure.
120
Oral disease associated with tobacco:
oral cancer
periodontitis
compromised wound healing
reduction in ability to smell, taste
smoker’s palate
melanosis
coated tongue
staining of teeth and restorations
implant failure
leukoplakia
121
What factors contribute to initiation of tobacco use during childhood and adolescence?
Aggressive marketing by manufacturers
smoking by parents
peer influence
functional belief in the benefits and normalcy of tobacco
availability and price of tobacco products
low SES
low academic achievement
lower self-image
lack of behavioral skills to resist offers
Teens who use tobacco are more likely to use ALCOHOL and other DRUGS and engage in high risk sexual behaviors
122
What % do tobacco smokers start by age 18?
90%
123
How is substance abuse different from substance dependence?
Abuse: maladaptive pattern of substance use manifested by recurrent/significant adverse consequences related to repeated use of substance
Dependence: Above, but includes tolerance (need for increased amount to achieve desired effect) and withdrawal
124
Substance abuse statistics among children –– about 1 in 5 kids:
- 21% Drink alcohol before age 13
- 24% Binge drink (\>5 drinks in a row)
- 20.8% marijuana
- 20% prescription drugs (oxy,perc,vicodin,adderall,ritalin,xanax)
- 20% students are smokers by the end of high school
42% alcohol
2% cocaine
125
What are the 5 A’s?
Brief intervention to treat tobacco dependence
For children, a 6th “A” has been added (first):
Anticipate
Ask
Advise
Assess
Assist
Arrange
