Oral Health and Dental Emergencies Maryland Assembly on School-Based Health Care Annual Conference May 19, 2015 Chief Reason Young Children Are Brought to Dental Office Parent describes the child s teeth as chipping or melting away. Norman Tinanoff, DDS, MS, Professor of Pediatric Dentistry, University of Maryland Childhood Caries Childhood Caries 18-Month-Old 36-Month-Old Epidemiology Etiology Prevention 1
Percent Percent of Children Caries and Treatment Levels in Arizona Children (n=5,171) Oral Health Status of Maryland Head Start Children (n=482) 60 50 40 30 20 10 0 0 12 24 36 48 60 Age in Months All Children with Caries Untreated Caries Partially Treated Caries Fully Treated Caries 9 8 7 6 5 4 3 2 1 0 All Children Children with Caries 3-yr-olds 4-yr-olds 3-yr-olds 4-yr-olds Decayed and Filled Surfaces Filled Surfaces Tang J, Altman DS, Robertson DC, et al. 1997. Dental caries prevalence and treatment levels in Arizona preschool children. Public Health Reports 112(4):319 329. Vargas CM, Monajemy N, Khurana P, et al. 2002. Oral health status of preschool children attending Head Start in Maryland, 2000. Pediatric Dentistry 24(3):257 263. Maryland Head Start Children Reporting Dental Pain Childhood Caries 20 18 16 14 12 10 8 6 4 2 0 All Children Children with Caries 3-yr-olds 4-yr-olds 3-yr-olds 4-yr-olds Epidemiology Etiology Prevention Complained of pain Cried from pain Vargas CM, Monajemy N, Khurana P, et al. 2002. Oral health status of preschool children attending Head Start in Maryland, 2000. Pediatric Dentistry 24(3):257 263. 2
The Dental Caries Process Enamel developmental defects Lack of topical fluoride Teeth Caries Bacteria Diet Tooth Factors High prevalence of enamel hypoplasia among children living in urban environments. Tooth mineral is lost if acid levels are low enough and if acid is in contact with the tooth for sufficient time. White spot lesion is first visual stage of mineral loss. Enamel Hypoplasia Tooth Factors High prevalence of enamel hypoplasia among children living in urban environments. Tooth mineral is lost if acid levels are low enough and if acid is in contact with the tooth for sufficient time. White spot lesion is first visual stage of mineral loss. 3
Salivary ph Drop Over 1 Hour After Sugar Intake Tooth Factors ph Sugar Intake Remineralization 7 6 5 High prevalence of enamel hypoplasia among children living in urban environments. Tooth mineral is lost if acid levels are low enough and if acid is in contact with the tooth for sufficient time. White spot lesion is first visual stage of mineral loss. Demineralization 1 Hour White Spot Lesions Bacterial Factors Bacteria attached to teeth metabolizes sugars to form acid. Cariogenic Mutans Streptococci are transmitted from mother/primary caregiver to child. Caries risk is higher for children who acquire Mutans Streptococci early in life. 4
Mutans Streptococci Mothers as a Source of Mutans Streptococci Paper Country Mother- Child Pairs Children with at Least One Genotype Identical to Mother Ersin et al. 2004 Turkey 8 100% Lindquist et al. 2004 Sweden 10 70% Klein et al. 2004 Brazil 16 81% Li et al. 2004 United States 37 89% Hames-Kocabas et al. 2006 Turkey 25 24% Bacterial Factors Dietary Factors Bacteria attached to teeth metabolizes sugars to form acid. Cariogenic Mutans Streptococci are transmitted from mother/primary caregiver to child. Caries risk is higher for children who acquire Mutans Streptococci early in life. Strong evidence that sugar, especially sucrose, fosters caries. Small increases in caries incidence if sugar is eaten with meals. Caries risk is greatest if sugar is consumed frequently. Certain sugars are less cariogenic than others. Certain foods are not cariogenic (e.g., milk, cheese, nuts, meats). 5
Salivary ph Drop Over 1 Hour After Sugar Intake Salivary ph Drop Over 1 Hour with Frequent Sugar Intake Sugar Intake Sugar Intake Sugar Intake Sugar Intake 7 Remineralization 7 Remineralization ph 6 ph 6 5 5 Demineralization 1 Hour Demineralization 1 Hour Drinks Frequently Consumed by Children Beverage Percentage of All Children (n=460) Juice 64.2 Milk alone 41.6 Water 34.7 Kool-Aid 20.8 Soft drinks 16.1 Tea 11.5 Milk and sugar 7.8 Vargas CM, Monajemy N, Khurana P, et al. 2002. Oral health status of preschool children attending Head Start in Maryland, 2000. Pediatric Dentistry 24(3):257 263. Company Fruit Juices Percentages of Juice and Sugar Label % Fruit Juice % Sugar Added Sugar Libby Juicy Juice 100 13 no Motts 100% Apple Juice 100 10 no Johanna Foods Ssips 10 12 yes Tropicana Twister Light 10 3 yes Procter & Gamble Sunny Delight 5 13 yes General Mills Squeezit 1 13 yes 6
Percentage with Height < 20th Percentile Percentage Overweight Juice Consumption and Height Juice Consumption and Weight 60 60 50 50 40 40 30 30 20 20 10 10 0 2-yr-olds 5-yr-olds 2- & 5-year-olds < 12 oz/day 12 oz/day Dennison BA, Rockwell HL, Baker SL. 1997. Excess fruit juice consumption by preschool-aged children is associated with short stature and obesity. Pediatrics 99(1):15 22. 0 BMI 75% BMI 90% Ponderal Index 90% < 12 oz/day 12 oz/day Dennison BA, Rockwell HL, Baker SL. 1997. Excess fruit juice consumption by preschool-aged children is associated with short stature and obesity. Pediatrics 99(1):15 22. Committee on Nutrition American Academy of Pediatrics No juice for infants under age 6 months. Infants over age 6 months can have 4 6 oz juice/day but not as a pacifying drink. Juice should always be offered to infants in a cup, not a bottle. Recommendation for toddlers and young children is the same as for infants. American Academy of Pediatrics, Committee on Nutrition. 2001. The use and misuse of fruit juice in pediatrics. Pediatrics 107(5):1210 1213. Dietary Factors Strong evidence that sugar, especially sucrose, fosters caries. Small increases in caries incidence if sugar is eaten with meals. Caries risk is greatest if sugar is consumed frequently. Certain sugars are less cariogenic than others. Certain foods are not cariogenic (e.g., milk, cheese, nuts, meats). 7
Salivary ph Drop of Various Carbohydrates Dietary Factors 7 Strong evidence that sugar, especially sucrose, fosters caries. ph 6 5 Starch, uncooked Starch, cooked Lactose Glucose Maltose Fructose Sucrose Small increases in caries incidence if sugar is eaten with meals. Caries risk is greatest if sugar is consumed frequently. Certain sugars are less cariogenic than others. Certain foods are not cariogenic (e.g., milk, cheese, nuts, meats). Cariogenic Potential of Children s Foods Childhood Caries Non-Cariogenic Low Cariogenic High Cariogenic Cheese Fruits Candy Milk Nuts Raw vegetables Whole-grain products Cookies Cake Sweetened beverages Epidemiology Etiology Prevention Popcorn Dried fruit Meat, poultry, and fish 8
Preventing Childhood Caries Identify developmental hypoplastic enamel. Reduce frequent, prolonged sucrose exposure. Prevent Mutans Streptococci transmission. Reduce level of Mutans Streptococci burden. Optimize systemic fluoride. Brush daily. Apply antimicrobial or topical fluoride (children at high risk). Receive early and frequent examinations. Parents /Caregivers Role in Prevention Follow appropriate food behaviors. Prevent Mutans Streptococci transmission (e.g., taste food with a different spoon, clean pacifier with water). Lift the lip and look for caries. Brush daily with less than a pea-sized amount (small smear) of fluoridated toothpaste. Fluoridated Toothpaste Amounts for Preschool-Age Children My Child Will Not Let Me Brush His Teeth Smear Under Age 3 Pea Sized Over Age 3 9
Fluoride Varnish Applied to All Surfaces of All Teeth States that Reimburse Medical Providers for Fluoride Varnish WA AK MT OR ID WY NV UT CO CA HI AZ NM = Medicaid coverage approved = In certain circumstances = Considering = Reimbursement not yet approved ND SD NE TX KS OK MN IA MO AR LA WI IL MS IN MI TN AL KY OH WV GA PA SC NC FL VA NY VT ME MA RI CT NJ DE MD DC DE RI NJ DC Revised: 07/09 NH Common Oral Findings Dental Emergencies Abscesses Associated with Dental Caries Immediate treatment dependent on abscess location and ability to anesthetize tooth. If delay, prescribe antibiotics and analgesics for 4 7 days. Oral penicillin 50 mg/kg/d in 3 4 divided dosages or Clindymcin 30 mg/kg/d in 3 4 divided dosages Ibuprofen 10 mg/kg/d q6 8 hours Parenteral antibiotics and hospitalization if celluitis spreads to facial triangle or submandibular space. 10
Abscess of Mandibular First Molar Can Be Anesthetized Abscess of Maxillary First Molar That Is Difficult to Anesthetize Abscesses Associated with Dental Caries Immediate treatment dependent on abscess location and ability to anesthetize tooth. If delay, prescribe antibiotics and analgesics for 4 7 days. Oral penicillin 50 mg/kg/d in 3 4 divided dosages or Clindymcin 30 mg/kg/d in 3 4 divided dosages Ibuprofen 10 mg/kg/d q6 8 hours Parenteral antibiotics and hospitalization if celluitis spreads to facial triangle or submandibular space. Abscesses Associated with Dental Caries Immediate treatment dependent on abscess location and ability to anesthetize tooth. If delay, prescribe antibiotics and analgesics for 4 7 days. Oral penicillin 50 mg/kg/d in 3 4 divided dosages or Clindymcin 30 mg/kg/d in 3 4 divided dosages Ibuprofen 10 mg/kg/d q6 8 hours Parenteral antibiotics and hospitalization if celluitis spreads to facial triangle or submandibular space. 11
Celluitis Affecting Maxillary Triangle and Submandibular Space Dental Trauma Maxillary Triangle Involvement Submandibular Space Involvement Collect standardized data from patient/parent Medical History Hospitalizations Medications Allergies Serious illness Under care of a physician Circumstances How When Where Examination Tooth Fracture Symptoms Unconsciousness Amnesia Headache Nausea Vomiting Previous dental injury to same area Disturbance of occlusion Extra-oral injuries 12
Avulsions Vital Therapy Tooth is out of the mouth for less than 1 hour. Transport medium: Reimplant (use finger pressure or bite into place). Medications: Antibiotics for 4 days. Tetanus vaccine. Treatment: Splint 1 2 weeks with semi-rigid splint. Follow up: 1 2 weeks then frequently thereafter. Prognosis: Guarded. Avulsions Non-Vital Therapy Tooth is out of the mouth for more than 1 hour. Medications: Antibiotics for 4 days. Tetanus vaccine. Treatment: Remove periodontal ligament. Remove pulp and obturate root canal. Place in 2% NaF for 20 minutes and reimplant after evacuation. Splint for 6 weeks. Prognosis: Good for short term and poor for long term. Splint for an Avulsed Tooth Root Fractures 13
Intrusions, Extrusions, and Luxations Alveolar Process Fracture and Treatment Reposition tooth into socket. Splint for 3 4 weeks. Monitor pulp healing. Injuries to Primary Teeth Injuries to Primary Teeth Trauma leading to nonvital tooth Follow for pathology (pain, abscess, or fistula) Root fracture Extract (root tip may not necessarily be removed) 14
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