Chapter 22

Adolescents and orthodontic patients

ADOLESCENTS

Between 11 and 19 years old, young people begin to take more responsibility for their lives. Changing to secondary education is regarded as a milestone in the United Kingdom, and children begin to challenge parental control and involvement in their general well-being.

By the mid-teenage years, adolescents have a full adult dentition (except for wisdom teeth), and may present with the same problems as adults (e.g. gingivitis, caries and erosion).

Young people in this target group will have opinions on what and when they eat. Peer pressure is strong, and in order to be part of the crowd snacking or grazing tends to be preferred. Media influence can play a large part in determining what the latest trend will be. Adolescents also go through growth spurts during these years and are frequently hungry between meals.

Treating adolescents

When dealing with this age group the oral health educator (OHE) should remember the following points:

• It is best to tackle one problem at a time (e.g. gingivitis). Dealing with too many problems at once is impractical for the professional and could be too much for the patient to cope with.
• Target the young person rather than the parent (be tactful and remember that the parents may wish to be involved or kept informed).
• Never patronise or ‘talk down’ to teenagers. Treat them as adults and they will usually respond appropriately.
• Try to find acceptable methods of communication/motivation – it may be more difficult to motivate boys, particularly in their early teens. Girls of this age are already concerned about their appearance, which can be a powerful motivational tool. Boys may respond to dental advice if it can be related to sports heroes.
• Remember that peer groups have an important part to play at this age – talking to adolescents in school or uniformed groups often works well and teachers/leaders may welcome dental talks as health care is included in the UK National Curriculum. Advice can be associated with ‘badge work’ in groups like Scouts and Guides.
• Intra-oral mouth piercing should be discouraged. Tongue bars and balls are known to damage teeth and cause recession (see Chapter 6). If already in situ, then oral health instruction will be required using a toothbrush or interspace brush to clean around them. Patients should be encouraged to remove them or replace with a plastic version to minimise damage.
• Be aware of bulimia and anorexia – look for signs (e.g. weight obsession, dramatic weight loss between appointments and tooth erosion). Erosion in this situation is commonly seen on palatal and lingual surfaces and the dentist may be the first health professional to identify a possible eating disorder. Careful and sensitive management is required.
• Also, be aware of smoking, alcohol and drug misuse. This can be a very sensitive topic, and a source of friction between adults and parents (see Chapter 13).

Consent

In England, Wales and Northern Ireland, children under 16 are not deemed to be automatically legally competent to give consent to procedures, but the courts have determined that they can be legally competent if they have ‘sufficient understanding and maturity to enable them to understand fully what is proposed‘ [1].

Department of Health guidance is that the families of children under 16 should be involved in decisions about their care, unless there is a very good reason for not doing so. But if, a competent child under 16 insists that their family should not be involved, their right to confidentiality must be respected, unless such an approach would put them at serious risk of harm.

Once children reach the age of 16 years, they are presumed in law to be competent. In many respects, they should be treated as adults and can give consent for their own surgical and medical treatment. But a child aged 16–18 years cannot refuse treatment if it has been agreed by a person with parental responsibility or the Court and it is in their best interests. Therefore, they do not have the same status as adults.

Advice for adolescents

Advice for adolescents should include the following topics [2].

Effective cleaning (see also Chapters 14 and 19)

Advice on effective cleaning should include:

• Toothbrushing – teenagers can usually cope with the Bass technique, but be flexible and do not insist on a particular technique if the patient is cleaning effectively.
• Toothbrushes – many teenagers use power brushes. Be prepared to demonstrate the use of these and advise on ordinary toothbrushes (size, texture and frequency of renewal).
• Toothpaste (a fluoride paste is important, 1400–1500 ppm) – check whether too much is being used. Many adolescents are avid watchers of TV adverts, where large amounts of toothpaste being squeezed onto brushes is often shown and copied. Reinforce no rinsing.
• Interdental cleaning – explain why it is important (using pictures or commercial leaflets). Bottle brushes, if carefully used, can be an acceptable alternative, particularly when an orthodontic appliance is in plac/>
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