Examination, Diagnosis, and Treatment Planning for General and Orthodontic Problems
Determination of Developmental Status
Related Hard and Soft Tissue Problems
Treatment Planning for Nonorthodontic Problems
Treatment Planning and Treatment for Orthodontic Problems
The classic portrayal of adolescence as a time of rising hormones, rebelliousness, and fads contrasts vividly with the way dentistry has viewed adolescent oral health. Dentistry for children ends abruptly with eruption of the permanent premolars and canines. Adult dentistry begins at the earliest with consideration of what to do with the third molars. For many dental professionals, the intervention that comes to mind first for the adolescent is orthodontic care, which is often begun during the preadolescent transitional period.
Entirely opposite to the prevailing beliefs about the quiescence of the teenage years is the reality of a rapidly changing patient challenging his or her environment head-on and learning to cope in the process. The implications of these changes for dentistry1 are summarized as follows:
1. Rapid, unpredictable, and irregular skeletal and dental growth. The adolescent growth spurt is associated with accompanying facial growth of up to 35% of total height of the face. More than a dozen teeth, primary and permanent, exfoliate and erupt between the ages of 10 and 13 years. Immunologic changes, hormonal shifts, and other subtle and not so subtle physical developments alter the oral cavity.
2. The environmental challenges, with their obstacles and pitfalls. Few adults would choose to return to adolescence. Drugs, smoking, sexually transmitted diseases, peer pressure, acne, more competitive education, career decisions, alcohol, and family pressure are some of the challenges that today’s adolescent must face. Perhaps the most poignant statement on this aspect of the teenage years is that accidental death is the leading cause of mortality. Dental professionals see trauma, oral manifestations of sexual activity, hormonal gingivitis, smokeless tobacco–induced hyperkeratosis, noncompliance with dental recommendations, and drug-related behaviors, to mention a few examples.
3. The need to learn to cope, make decisions, and become independent. It is not surprising that primitive cultures associated emerging adulthood with rituals and great significance. Adolescence has always been a time to make decisions, seek independence from families, deal with sexuality, and choose a career. The dentist may see this turmoil reflected in poor compliance with oral hygiene or refusal to accept treatment. The missed appointment is just one of many ways to say, “I am too involved in my search for self, my changing values, and handling my environment to worry about my teeth.”
The Patient History
The health history of the adolescent is constantly changing and must be kept current. An adult history format captures both of these elements. Perhaps more important from the standpoint of accuracy is the process of obtaining information from the teenager. The following are some of the topics that should be considered when taking a history from an adolescent patient.
The health history should address the issues of smoking, recreational drugs and alcohol, birth control, pregnancy, and sexually transmitted diseases. The controversy over inclusion of these issues is easily quieted by the simple realities of adolescent life in the United States. Consider the facts:
• Every day, approximately 3000 teenagers start smoking.
• Out-of-wedlock births have increased by 50% in recent years.
• Radiation and medications used in dentistry can be dangerous to a fetus.
• The majority of adolescents now try drugs or alcohol before leaving high school. Untoward interactions between prescribed and illicit medications can be fatal.
• Sexually transmitted diseases are epidemic in the adolescent age group.
Inadequate surveying of these elements of the health history puts both dentist and patient at risk. These issues can be addressed forthrightly by including them as choices interspersed with others on a health history form. A less threatening approach is to phrase these questions in the past tense or to associate a risk with them in order to alert the patient to their importance.
The history-taking process should allow privacy and encourage disclosure. Taking an accurate history may mean allowing the adolescent to assume greater participation in the process. The desired yield on the adolescent history from this perspective is information that might not be available from or known to a parent, such as those items described previously. The dentist may be caught in a double bind by providing an environment that fosters disclosure if pregnancy or illicit drug use is uncovered and the parents are unaware of it. This is a risk that requires counseling and resolution before dental treatment, and the dentist’s responsibility is to help direct the family to address the issue. Unfortunately, the adolescent may see this as betrayal or breach of confidence, and the relationship between the dentist and patient may be jeopardized. There is no easy way to deal with this type of problem, but the dentist who treats adolescents should be aware of the responsibilities of the situation. It also may mean delaying treatment until the problem is resolved.
The dentist can take some actions that both facilitate an accurate history and deal consistently with identified problems of a serious nature:
• Encourage parents to complete histories with adolescents, not for them.
• Allow the adolescent the opportunity to contribute to the history alone, which can be done in the context of a final check before treatment at chairside.
• Never treat an adolescent without a consenting parent available. Dental care would be considered nonurgent care and most jurisdictions require adult consent.
• Explain suspicions or concerns to both parent and adolescent.
• Establish a policy on deferring treatment and dealing with identified problems of a serious nature that is medicolegally consistent and sound.
• Have resources available in case consultation with a specialist is needed. It is far better to have an established professional relationship than to seek help from a stranger.
The techniques of clinical examination remain the same for the adolescent, but closer attention is paid to identification of problems specific to this group, such as occlusal disharmonies, periodontal conditions, and temporomandibular joint disorders. Table 37-1 lists some of the clinical findings peculiar to adolescent patients.
The access to dental care available to most healthy Americans has made it unlikely that a teenager will present for a first visit at that period in life, although first visits during adolescence are possible. Most people have made at least one visit to a dentist before they reach adolescence. Personality changes and other behavioral aberrations can suggest problems for the adolescent. Extremes in behavior, such as depression or overt flirting, may indicate sexual abuse in the adolescent girl, especially if the child demonstrates a reluctance to allow oral examination. Depression, manifested by severe introversion, can also be a sign of suicidal tendency, family dysfunction, or even drug use. It is not the dentist’s responsibility to diagnose or manage these kinds of problems, but the dentist should be aware of the impact of the problem on the child and comment to parents about noticeable changes in behavior. Few behavioral problems should be encountered that will preclude delivery of care, but exceptions do occur. The following are situations that may require behavioral management:
1. Sexual abuse. The young adolescent girl or boy who has been sexually abused with oral penetration may be reluctant to accept dental care from a dentist of the same sex as the perpetrator. Aids in uncovering this situation are a good history of previous compliance, behavioral cues such as depression, and overt refusal of care when oral contact is made. Nonetheless, confirmation is difficult because the parents may be unaware of the abuse. It may be the limit of the dentist’s role to recommend counseling for such a child in the hope that intervention may uncover the cause.
2. Rampant caries. Clinicians have noted that rampant caries, a condition of rapid onset and progression of decay in an adolescent (more often a girl), is often associated with personality problems (Figure 37-1). The typical manifestation is a shy, reluctant, introverted person who is passive about treatment. The behavioral signs can be varied, with the girl crying silently or not saying a word during the appointment. In some cases, appointments can degenerate as the child whimpers and finally loses her composure. Time and engagement in conversation are often the most successful behavioral management keys in dealing with these adolescents. Dramatic changes in behavior can occur with the dentist’s verbal reinforcement of improved hygiene and provision of even temporary aesthetic anterior restorations that allow the patient to smile and experience a more positive self-image.
FIGURE 37-1 This 14-year-old girl has rampant caries, which is a distinct clinical entity with rapidly progressing decay, multiple pulpally involved teeth, and short onset. Patients may give a history of minimal caries before development of overt signs of decay.
3. Extreme anxiety. Pinkham and Schroeder2 described the behavioral management of the child who shows extreme anxiety at the prospect of dental treatment. Desensitization by psychological intervention may be the key to development of acceptable clinical behavior in such children. Tools available to the dentist are the use of noninvasive therapies at first, reinforcement of positive accomplishments, positive peer interaction, and involvement with a psychologist. The poorly treated or untreated adolescent phobic may become the adult dental phobic.
4. Eating disorders. Treatment of the child with an eating disorder can be difficult. Experience indicates that these patients, disproportionately girls, tend to develop dependency on a male authority figure. They also require a dentist’s full attention during office visits and, unless counseled, may demand time outside scheduled appointments.
5. Illicit drug use. Clinicians have noted bizarre behavior on the part of adolescents and young adults who present for treatment after taking nonprescription medications. A number of untoward reactions to dentist-administered medications have been associated with prior ingestion of drugs or alcohol by a young patient. Manifestations of drug ingestion may vary from a slight mental dissociation or drifting to outright verbal aberrations or extreme changes in personality.
Another common drug used by adolescents is nicotine as either cigarettes or smokeless tobacco. This drug is addictive and has cardiovascular, respiratory, and oral consequences. Although it is difficult, cessation programs combining willing and motivated participants using nicotine replacement therapy combined with behavioral support seem to have the best chances of interrupting the habit.
Management of behavioral problems in the adolescent can be complex and often involves parents and other professionals. On the other hand, a number of adolescents show age-appropriate behavior that may be disruptive to delivery of care. Most practitioners treating adolescents try to treat these patients alone rather than in a setting in which other peers are present. This one-on-one relationship provides the necessary attention to the patient and prevents disruptive interactions. Any dentist who has worked with a group of seventh or eighth grade students will appreciate this recommendation. The teenager who is acting up but is simply expressing healthy emotions should respond to reason and provide compliance.
An important part of behavior management in this age group involves the simple transfer of information. A good communicator is aware of the characteristics of adolescence, which enhances his or her ability to relate to teenagers. These characteristics are as follows:
1. Peers are important. The adolescent’s relationship to those outside the nuclear and extended family becomes important. Friends, classmates, teammates, and popular persons of similar age are all involved in the life of the teenager. A dentist can enhance his or her ability to communicate with adolescents by asking about peer interaction and by knowing who is involved in the teen’s life.
2. Fads and experimentation are part of adolescence. Successful adolescent practitioners are those who are aware of the trends, popular fads, and celebrities that are of interest to teens. A clear demonstration of this to teens is the presence of posters or contemporary music in the operatory. The dentist who knows the trends and interests of the adolescent has an edge in establishing communication and in reaching the teen on a nonauthoritarian basis. These are an entree into the teen’s world that can be fostered and can lead to discussion of more significant issues with a sense of relationship. Contrast that access to the barrier that arises when both teen and dentist see themselves as worlds apart.
3. Teens are trying to establish independence, searching for identity, making educational or career choices, and experimenting with sexuality. All of these involve a certain degree of stress. Within that stressful period are times of anxiety, satisfaction, anger, excitement, and a host of other emotions. The dentist is a small part of the adolescent’s world but is a mirror of it. How the practitioner fosters the healthy development of personality in a child and counsels him or her toward independence and career may be important in terms of both the teen’s life and his or her dental health. In talking with teens, it is helpful to remember their “problem list” and to empathize about the stress of their lives, which is real to them. The office visit should be a mirror of life. It should provide a respite from pressures and be a cameo of the role that the adolescent plays as an adult patient. The relationship that the dentist would like to have with the adolescent as an adult should be fostered.
4. The basis of success in adolescent-adult interactions is a good relationship. The most significant factor in successful compliance and communication is the quality of the relationship between the dentist and the adolescent. In earlier periods of life, the child could be successfully motivated with reason, praise, or other approaches. The changing values and their short-term intensity in adolescence belie the use of these approaches in fostering long-term motivation. A feeling of trust, good communication, and a perception by the teenager of the dentist’s sincere interest provide a strong motivation for compliance.
The general appraisal of the adolescent is confounded by the timing of physical growth changes, especially in the early teenage years. Within a group of young teenagers, girls can tower over boys and look far more like adults than their male peers. Similarly, within a group of boys, variations in voice tone, skin condition, amount and distribution of fat, and skeletal proportion are often remarkable. Differentiation of growth disorders is difficult at best.
Determination of Developmental Status
Patients in the preadolescent stages are growing rapidly and many clinicians prefer to attempt growth modification then. If that can be tied to the transition to the permanent detention, then one stage of treatment can be sufficient to complete the care, exclusive of retention. For others, early treatment may be required followed by a final phase of comprehensive treatment near the end of the transition from the mixed to permanent dentitions. After peak growth, statural and facial growth decrease dramatically. At that point, either camouflage or surgical orthodontic treatment are the only logical options for care.
The most important question usually faced is whether patients are still growing facially, so that the timing of surgical care can be instituted for those with excess growth issues like mandibular protrusion or vertical excesses. The most reliable and sensible method, which speaks directly to this issue, is taking serial cephalometric radiographs and superimposing their tracings (see Figure 30-53). This method is helpful not only for orthodontic treatment planning, but also for determining when implant placement is feasible relative to vertical facial growth.
Head and Neck Examination
The principles of the head and neck examination of the teenager are similar to those applied to the adult or child. Variations from normal can be caused by a variety of factors, the most notable of which are growth and developmental changes and the effects of the adolescent’s environment.
The physical changes and habits in the teen require modification of the procedures used in children. On the positive side, the loss or redistribution of body fat and the elongation of the neck allow one to perform a better lymph node evaluation. These changes facilitate a thorough head and neck and cancer examination.
In the facial examination the dentist analyzes the soft tissue profile and the frontal face. During adolescence the face is beginning to assume adultlike features, and treatment decisions can be based more on current rather than on projected facial appearance. This does not mean that growth is complete, only that it has slowed considerably from its previous pace during the early adolescent growth spurt. The adult profile tends to be straighter than the adolescent’s because of continued mandibular skeletal growth. In addition, the soft tissue of the chin increases slightly in thickness. The nose also continues to grow, both horizontally and vertically. Most of this growth is horizontal, but the nasal tip tends to drop down a small amount. The lips are less protrusive in the adult because of these nasal and chin changes combined with a slight thinning of the soft tissue thickness of the lips.
For patients with class I skeletal and dental characteristics, the facial profile examination should provide an adequate basis for analysis when minor orthodontic treatment is considered. For the patient with a skeletal problem, a cephalometric radiograph and analysis are required to diagnose the problem definitively and prescribe treatment.
Treatment for skeletal orthodontic problems during preadolescence or early adolescence, when the adolescent growth spurt is still active, can result in growth modification. The preadolescent patient is assumed to be growing and is expected to experience a pubertal growth spurt. The young adolescent, especially the male, still has enough growth remaining to allow significant skeletal changes to occur with treatment. The adolescent by definition has experienced the pubertal growth spurt and is on the down side of the growth rate curve. Adults, on the other hand, have such limited facial growth that it is of little therapeutic potential.
These differences in growth potential have a large impact on how skeletal malocclusion is managed in the adolescent. The point is that as the individual becomes more skeletally mature, less skeletal growth modification can be accomplished. Therefore, as noted earlier, it is essential to establish the growth or developmental status of the patient in order to plan sensible treatment.
The larger size of the adolescent oral cavity permits good visualization. Also, normal intellectual status and reasonable behavior provide cooperation in functional assessment of the occlusion and the temporomandibular joint. On the negative side, there are more teeth to evaluate, gingival and periodontal issues are present that were not critical in early childhood, and unpredictable growth changes can occur. The clinician should approach the adolescent as an adult, especially in the later teen years. For the first visit, the dentist may choose to “walk” the adolescent through the examination, using a hand mirror to explain procedures and normal findings.
In the adolescent more emphasis is placed on the periodontal examination. The prevalence of periodontal disease begins to increase in this age group.3 The reason for this increase in periodontal disease is unknown at this time. Therefore a thorough evaluation of the supporting structures is an absolute necessity. A periodontal probe is used to measure pocket depths, the width of keratinized gingiva, and the amount of attached gingiva, and to establish a bleeding index (Figure 37-2). Periodontal probing should be confined to fully erupted teeth. Mobility tests may reveal slightly increased mobility in erupted teeth without complete root formation. The use of disclosing agents to reveal plaque, though helpful, may be discontinued at the patient’s request. If a panoramic radiograph is used for diagnosis, selected periapical films may be needed if the clinical examination exposes any unusual periodontal findings. Referral to a specialist is suggested if significant periodontal disease is evident. During orthodontic treatment, gingival, plaque, and bleeding indices should be established at regular intervals to detect newly active periodontal disease. Over the next decade, the increase in overweight and obesity with attendant increase in early-onset diabetes may yield more adolescents with early periodontal disease and bone loss. But to date, studies are equivocal on this relationship and dentists should simply include periodontal evaluation as a part of the adolescent examination.
FIGURE 37-2 The prevalence of periodontal disease begins to increase in the adolescent patient; therefore a thorough evaluation of the periodontium is absolutely necessary. A periodontal probe is used to measure pocket depth (A) and the width of the keratinized gingiva (B). Probing is also done to establish a bleeding index (C). The amount of attached gingiva is determined by subtracting the pocket depth from the width of the keratinized gingiva.
Related Hard and Soft Tissue Problems
A number of pathologic conditions may occur in adolescence and may be first noticed in this period. One is temporomandibular joint disorder (TMD), described in more detail later in this chapter. An eating disorder can manifest as enamel erosion of all teeth if vomiting is a regular component of this psychiatric disorder.4 Bulimia is the term given to characterize those who vomit regularly to purge themselves of food in a misdirected attempt to control their weight. Bulimia affects far more girls than boys, but boys can exhibit similar behavior. The regurgitated stomach contents, which are highly acidic, erode the enamel of teeth in a process called perimolysis (