Oral Health QUESTIONS

Transcription

1 Oral Health COMPENTENCY The resident should understand the timing of tooth development. The resident should recognize the clinical picture of bottle caries. In addition, the resident should know the current guidelines for fluoride supplementation and be able to advise parents on toothbrushing and developing a dental home. CASE A family comes to you for well check-ups for both of their children after recently moving to town. Their children are Johnny, 2 years old, and Rose, 4 months old. They recently moved from a rural area of the country into the big city, and they are setting up all of their health care here in town, including trying to find a dentist. In the course of the interview, you learn that Johnny still goes to sleep with a bottle. He brushes his teeth every day and usually spreads the family toothpaste over his whole toothbrush. Mom has recently noticed some dark areas on his upper teeth. Rose is putting her hands in her mouth all the time, and mom thinks she might be teething, but otherwise is doing well. QUESTIONS 1. Mom gave Johnny fluoride supplements when he was a baby and wants advice on supplementing her children now. What do you counsel mom on fluoride and its risks and benefits? 2. What are the current recommendations for fluoride supplementation? 3. Mom is concerned about the changes in Johnny s teeth and would like some advice on what she can do about it. What can you tell mom about bottle caries? 4. Please provide the mom with appropriate anticipatory guidance and counseling regarding her children s tooth development. 5. How should mom care for her children s teeth and prevent them from getting cavities? 6. Mom agrees to take Johnny to the dentist and would like help deciding when Rose should see the dentist also. REFERENCES 1. Lewis CW, Milgram P. Fluoride. Pediatrics in Review. 2003; 24(10): Martof A. Dental Care: Consultation with the Specialist. Pediatrics in Review. 2001; 22(1): (go to oral health section) Policy Statement: Oral Health Risk Assessment Timing and Establishment of the Dental Home. Pediatrics. 2003; 111(5):

2 Oral Health COMPENTENCY The resident should understand the timing of tooth development. The resident should recognize the clinical picture of bottle caries. In addition, the resident should know the current guidelines for fluoride supplementation and be able to advise parents on toothbrushing and developing a dental home. CASE A family comes to you for well check-ups for both of their children after recently moving to town. Their children are Johnny, 2 years old, and Rose, 4 months old. They recently moved from a rural area of the country into the big city, and they are setting up all of their health care here in town, including trying to find a dentist. In the course of the interview, you learn that Johnny still goes to sleep with a bottle. He brushes his teeth every day and usually spreads the family toothpaste over his whole toothbrush. Mom has recently noticed some dark areas on his upper teeth. Rose is putting her hands in her mouth all the time, and mom thinks she might be teething, but otherwise is doing well. QUESTIONS 1. Mom gave Johnny fluoride supplements when he was a baby and wants advice on supplementing her children now. How do you counsel mom on fluoride and its benefits and risks? Fluoride is an element that acts to prevent dental caries. It is active in several ways, including enhancing tooth mineralization, stopping tooth demineralization, and working against the bacteria in the mouth that produce acid that leads to cavities. The risk of excessive intake of fluoride is developing fluorosis. Fluorosis in its most severe form is skeletal, which is very rare. Most fluorosis affects the enamel of teeth and causes anything from mild lacy markings on the enamel to striations and pitting of the teeth. The more severe form of enamel fluorosis actually puts one at greater risk for developing caries. The risk of fluorosis only applies to children under the age of 8, whose permanent teeth are still developing. In particular, children months are at greatest risk of suffering the adverse affects of excess fluoride as that is when the anterior permanent teeth are most vulnerable to fluorosis. There are many sources of fluoride, including community water, bottled water, foods and beverages, toothpaste, mouthrinses, and oral and topical supplements. Water is naturally fluoridated, but not always to optimal levels. Thus, fluoride is added to most community water according to region, and different areas have different amounts of fluoride (you can find the fluoride content of water in your area on the Optimal concentrations are 0.7 to 1.2 ppm. Most well-water has sub-optimal levels of fluoride. It is important to inform parents that in most urban areas, the level of fluoride in the community water is sufficient to provide a young child with protection prior to the age of brushing, but levels that exceed 2 ppm should not be given to children under the age of 8 due to an increased risk for fluorosis at that level. In addition, it is a little known fact that foods and beverages are usually

3 prepared using community water sources with fluoride, fluoride is entering diffusely via these products into communities, including those communities that do not fluoridate their water supply. Cooking with tap water in fluoridated communities also adds fluoride to foods. On the other hand, bottled or nursery water may or may not provide the infant with fluoride, as these water sources are not always fluoridated. Parents also need to understand that reverse osmosis and charcoal water filters can greatly decrease the amount of fluoride in the water cleaned with home water filtering systems. In Chicago, a 1 year old child needs about 1 liter of fluoridated water each day to meet fluoride needs. 2. What are the current recommendations for fluoride supplementation? The current guidelines for fluoride supplementation for children living in areas of unfluoridated community water are as follows: Water fluoride content (ppm) Age > to 0.6 > 0.6 Birth to 6 mo 0 mg 0 mg 0 mg 6 mo to 3 y 0.25 mg 0 mg 0 mg 3 y to 6 y 0.50 mg 0.25 mg 0 mg 6 y to 16 y 1.00 mg 0.50 mg 0 mg Considering the fact that this patient is living in an urban area that most likely has > 0.6 ppm fluoride in the water supply (when she previously lived in a rural area that may have had > 0.3), she does not need to supplement either of her children with oral fluoride. Please see the section on general anticipatory guidance and counseling regarding information on toothbrushing and the use of fluoride in toothpaste. 3. Mom is concerned about the changes in Johnny s teeth and would like advice on what she can do about it. What can you tell mom about bottle caries? Johnny has developed bottle caries. Putting a baby or child to bed with a bottle of milk or juice provides the teeth with prolonged contact with sugary substances, leading to the development of caries. These caries are usually found in the upper anterior teeth and the posterior teeth, because the lower front teeth are shielded from the fluid by the lip and tongue. Mom should be counseled to stop giving a bottle of milk or juice to Johnny at bedtime. Mom can be advised to simply wean Johnny off of the bottle altogether (one should counsel parents to stop using a bottle entirely around 12 to 14 months of age). Any bottle the mom may give at bedtime in the meantime should contain only water. In addition, Johnny should be referred to a dentist immediately for restoration or removal of the affected teeth. 4. Please provide the mom with appropriate anticipatory guidance and counseling regarding her children s tooth development? The following chart outlines the general timing of tooth development.

4 Age Tooth eruption 6-10 months Lower central incisors 8-12 months Upper central incisors 9-16 months Lateral incisors 16 months - 3 First molars, canines, second molars (usually in that order) years 6 years and up Permanent teeth (central incisors first, then other incisors and molars Teenage years 3 rd molars Teething infants may be excessively drooly and cranky, and are often soothed by use of a chilled teething ring or appropriate dosing of an oral analgesic (i.e. acetaminophen or ibuprofen). Topical analgesics have not be shown to be beneficial, but can be used at small doses. Fever, diarrhea, and other systemic symptoms are often attributed to teething but have not been shown to be associated with teething in controlled studies. 5. How should mom care for her children s teeth and protect them against getting cavities? As soon as the baby s first teeth erupt, parents should begin to wash their children s teeth twice a day. This may be done at first by simply wiping with a wet cloth. As the child becomes old enough (nearing 1 year), the child can start brushing with a soft infant/child toothbrush in order for the child to learn the behavior of toothbrushing. In addition, teeth should be flossed once daily as soon as the teeth make contact with one another. A risk assessment should be used when counseling a family about the use of a fluoridated toothpaste in a child under the age of 2.5 years, due to the need to balance the need for fluoride protection with the higher risk of fluorosis, as these children will likely swallow large amounts of toothpaste. High risk children (those in non-fluoridated water areas, have siblings with significant tooth decay, are exposed to high levels of sugary substances, have visible plaque or white spots or caries on teeth, are of low socioeconomic status) may be advised to use a child s toothpaste that contains low levels of fluoride. When using fluoride toothpastes, parents should be counseled on using a pea-sized amount of toothpaste only, to minimize the risk of swallowed fluoride. Low risk children (those not falling into the above categories), should use non-fluoridated toothpastes only (if any toothpaste at all), since the risks of swallowing outweigh any potential benefits. Mom should be counseled on the avoidance of cariogenic foods, such as high sugar foods ( junk foods ) and those foods that get stuck in the teeth (i.e. raisins and peanut butter). One idea is limiting junk to 1 hour a week and promptly cleaning the teeth after ingestion of these foods. Juice should be limited to 1 cup a day (6 oz). Children should not ingest carbonated beverages. 6. Mom agrees to take Johnny to the dentist and would like help deciding when Rose should see the dentist also.

5 Previously, the AAP recommended children to first see a dentist at 3 years of age. The most recent ADA and AADP recommendation is to refer patients for a first dental visit between 12 and 18 months. This visit allows the child to be introduced to the idea of the dentist and for further evaluation of the child s oral health and anticipatory guidance for the family. It is best to call ahead and ensure that the dentist does accept young children, as there are some dentists who do not feel comfortable treating young patients. Children with special needs (i.e. developmental delay, trach/vent) should be referred to university or pediatric dentists for routine dental care. REFERENCES 1. Lewis CW, Milgram P. Fluoride. Pediatrics in Review. 2003; 24(10): Martof A. Dental Care: Consultation with the Specialist. Pediatrics in Review. 2001; 22(1): (go to oral health section) Policy Statement: Oral Health Risk Assessment Timing and Establishment of the Dental Home. Pediatrics. 2003; 111(5): Reviewed by Dr. Karen Goldstein