Prevention of Dental Disease

Tad R. Mabry, Arthur J. Nowak and Henry W. Fields, JR.

Adolescence generally denotes the period between childhood and adulthood. However, adolescence also is known for being a period of change, rebellion, friction, and problems. It is a period when the patient progresses from junior high school to senior high school and then goes off to college, the work force, or some other aspect of adult life. It is a period of heightened involvement in peer group relationships, often at the expense of social or familial associations.

The period encompasses the completion of physical growth and development in both girls and boys. All permanent teeth have erupted except for the congenitally missing or impacted third permanent molars. The occlusion has stabilized either on its own or with orthodontic intervention. Most studies show a gradual but general increase in the incidence of dental caries during this period.¹ Periodontal disease may become clinically evident because there are fewer routine and supervised home care sessions as well as less frequent professional interventions. In addition, the increase in sex hormones in this age group is suspected to alter the subgingival microflora, resulting in an increased incidence of periodontal disease.²

Dietary habits undergo dramatic changes during this period. As adolescent girls complete their maximal growth and development and begin the long process of “figure development,” it is not unusual for them to begin dietary experimentation and modification. Some of these modifications can lead to serious pathologic conditions such as anorexia nervosa and bulimia. In adolescent boys, similar modifications in dietary habits occur. During this period the boy’s skeletal growth and body weight usually undergo dramatic changes, peaking at around age 16 to 18 years. Caloric requirements increase dramatically, and large amounts of protein and carbohydrates are consumed. In both groups, irregular meals, fast-food meals, frequent snacking, vending machine purchases, and unusual eating patterns are all common.

These changes, which have been so frequently described and routinely observed, can have profound effects on the oral environment and pose substantial challenges for the provision of professional dental care. If the individual has had the advantages of both systemic and topical fluorides, the problem of caries is usually confined to the occlusal surfaces of the posterior teeth. However, the eruption of posterior teeth into an environment of increased plaque secondary to reduced cleansing combined with frequent snacking on foods and beverages high in carbohydrates can also pose a significant risk for caries development in the immature enamel of smooth surfaces.

Besides being a time of increased caries risk, adolescence is also a time when the desire for social acceptance leads individuals to actions that place them at risk for additional dental complications. Examples of such actions would include tobacco use, intraoral and perioral piercings, and adolescent pregnancy. Periodic professional visits combined with an emphasis on continuing home care, optimal use of topical fluorides, assistance in dietary management, and counseling on the dental implications of risky behaviors are both the goals and the challenges for the dentists who treat adolescents.

Risk Assessment

Risk assessment takes on some added dimensions for the adolescent patient. Through the years, these individuals have become increasingly responsible for their own oral hygiene practices. Typically, it is the first time in their lives that they have a say in the decision-making process associated with their dental treatment options. Though treatment decisions are legally still in the hands of the parents or legal guardians, the wills and desires of the adolescent patient should not be discounted by the provider.

The American Academy of Pediatric Dentistry (AAPD) has developed a set of guidelines used to assess the caries risk of patients in the mixed or permanent dentition (Table 38-1). In addition, the AAPD has developed caries management protocols based on these risk assessments (Table 38-2). Although these protocols are useful in determining the direction of patient care, they should be considered as guidelines only, and each adolescent should have an individualized treatment plan that addresses their unique preventive, restorative, and counseling needs.

TABLE 38-1

Caries-Risk Assessment Form for Patients Older than 6 Years (For Dental Providers)

Circling those conditions that apply to a specific patient helps the practitioner and patient/parent understand the factors that contribute to or protect against caries. Risk assessment categorization of low, moderate, or high is based on preponderance of factors for the individual. However, clinical judgment may justify the use of one factor (e.g., >1 interproximal lesion, low salivary flow) in determining overall risk.

Overall assessment of the dental caries risk: Low Moderate High

From American Academy of Pediatric Dentistry: Guideline on caries-risk assessment and management for infants, children, and adolescents, Pediatr Dent 33:110–117, 2011.

TABLE 38-2

Example of a Caries Management Protocol for Patients Older than 6 Years

^*Indicated for teeth with deep fissure anatomy or developmental defects.

^†Less concern about the quantity of toothpaste.

^‡Periodic monitoring for signs of caries progression.

^§Need to consider fluoride levels in drinking water.

Careful monitoring of caries progression and prevention program.

From American Academy of Pediatric Dentistry: Guideline on caries-risk assessment and management for infants, children, and adolescents, Pediatr Dent 33:110–117, 2011.

The caries risk assessment comprises just one part of the overall risk assessment for the adolescent patient. Other factors that must be considered when developing a comprehensive treatment plan include the need for as well as the timing of referrals for orthodontics or third molar extractions where indicated. Risk factors such as pathologic dietary conditions, tobacco use, alcohol or drug abuse, intraoral or perioral piercings, or teenage pregnancy must be factored in when treatment planning care for the adolescent. Counseling that addresses the dental as well as the medical complications associated with these risk factors should be included as part of the comprehensive treatment plan. If a provider is not comfortable or feels that further counseling expertise is warranted, a referral should be made to a professional who could provide such counseling.

Anticipatory guidance is the implementation of preventive strategies based on a risk assessment. It is more desirable to preemptively provide education that might prevent the development of a pathologic condition than to treat the condition once it has occurred. For the infant or toddler, a caries risk assessment will typically dictate the focus of education in order to minimize the odds of development of early childhood caries. For the adolescent patient, anticipatory guidance not only includes caries reduction strategies based on a caries risk assessment, but also includes preventive measures aimed at reducing the likelihood that adolescents would choose to participate in behaviors that could jeopardize their oral health. Adolescents often participate in these types of activities without knowing the negative consequences associated with them. The goal of this form of anticipatory guidance is to educate adolescents on the detrimental effects associated with these risky behaviors in hopes that they may elect not to participate in these activities when pressured by their peers.

Several organizations such as the AAPD as well as the American Academy of Pediatrics (AAP) and the American Dental Association (ADA) have educational materials in the form of pamphlets and brochures that can be used to guide the discussion that a dental professional may have with the at-risk adolescent.

Dietary Management

As with younger age groups, the overall recommendations on dietary management for adolescents should concentrate on balanced intake, reduction of the frequency of snacking, and selection of foods that are not retentive to the teeth and soft tissues. Unfortunately, these recommendations conflict with the typical lifestyles of adolescents. With their newly gained independence, rebellious attitude toward established social systems, and acceptance of media messages and peer group pressure, it is a difficult task for the dentist and his or her staff to communicate recommendations and instill health-promoting behaviors.

Fortunately, owing to the increasing social development that occurs in middle adolescence, there is a strong desire to look attractive; and the mouth, being the center of the face, takes on added importance. The challenge to dental professionals is to somehow make the daily care of teeth, including sound dietary habits, desirable for this group.

For the patient who has been at high risk for dental disease during the early years and has had caries in the primary or mixed dentition, dietary management is a major concern. Depending on the patient’s present oral status, emotional and psychological maturity, and parental influences, counseling can be performed with the patient only or, if indicated, with the parents. At this age the adolescent may enjoy independence from the involvement of the parents. The dentist must decide whether to include the parents and to inform the parents about the results of the dietary counseling.

The sense of independence among adolescents often leads to snacking at will. Such poor eating habits are a major factor in the increasing rates of childhood obesity.³ Often these poor eating patterns carry over into adulthood. The National Health and Nutrition Examination, 2005-2006 (NHANES) investigated the change in snacking habits of adolescents since the late 1970s. Several troubling issues were identified:

• The number of adolescents who snack on a given day increased from 61% in 1977-1978 to 83% in 2005-2006.

• Snacking, which accounted for 300 calories a day in 1977-1978, accounted for 526 calories a day in 2005-2006.

• Those adolescents who snacked frequently were more likely to have a higher total daily calorie intake.⁴

The busy lifestyles of adolescents today make the sit-down family meal a rarity. This has a deleterious effect on the dietary patterns of adolescents. Research has shown that parental presence at family evening meals exerts substantial influences in terms of the adolescents’ consumption of fruits, vegetables, and dairy products.⁵

A growing trend among adolescents is the consumption of sports drinks and energy drinks (Figure 38-1). Adolescents, as well as their parents, often fail to recognize the difference between these two.⁶ Sports drinks are promoted by the beverage industry as products that optimize athletic performance by replacing fluid and electrolytes lost in vigorous exercise. In contrast, energy drinks purport everything from an increase in energy and a decrease in fatigue to enhanced mental alertness and focus. These energy drinks typically contain a blend of stimulants that include caffeine, taurine, ginseng, guarana, l-carnitine, and creatine. Some of these energy drinks exceed 500 mg of caffeine in a single serving, which is equivalent to the amount of caffeine found in 14 cans of the typical caffeinated soft drink.⁷ Caffeine adversely affects the physiologic as well as the mental function of an individual. It tends to increase blood pressure, heart rate, gastric secretions, body temperature, cardiac arrhythmias, and diuresis.⁸ For those individuals with increased anxiety, it makes them more prone to anxiety disorders.⁹

FIGURE 38-1 Sport drinks (A) versus energy drinks (B).

Both parents and school systems are recognizing the harmful dental effects of carbonated sodas and similar beverages and limiting the exposure of adolescents to them. Unfortunately, these carbonated beverages are frequently being replaced with sports drinks. The pH of most sports drinks are in the acidic range (pH 3 to 4), which is well within the range to cause enamel demineralization.¹⁰ It is unfortunate that parents and school administrators are failing to recognize the deleterious effects of sports drinks on the dentition.

The American Academy of Pediatrics Commission on Nutrition (COM) and the Council on Sports Medicine and Fitness (COSMF) recently published a report with the following recommendations to pediatricians:

• Improve the education to both parents and children on the differences as well as the potential health risks of sports drinks and energy drinks

• Understand the potential health risks that energy drinks pose as a result of their stimulant content

• Counsel at-risk individuals as to the relationship between both obesity and dental erosion to excessive sports drink consumption

• Educate patients and parents on effective hydration management, stressing that water should be the initial beverage of choice for hydration purposes

According to the commission’s report, energy drinks have no place in the diet of adolescents.¹¹

Although sports drinks and energy drinks are a somewhat new trend among adolescents, the problem associated with the consumption of high-sugar beverages of any type is long-standing in this age group. Sugar-sweetened beverages have become the largest source of added sugars in the diet of adolescents in the United States.¹² These beverages include nondiet sodas, sweetened fruit juices, sweetened coffee and tea drinks, and the sport and energy drinks. Some studies are attributing the increased caloric intake associated with the consumption of these beverages as a factor that is contributing to the increasing obesity rates among adolescents.¹³ In addition, the high sugar content of sugar-sweetened beverages has been shown to increase the risk of type 2 diabetes by increasing the dietary glycemic load, leading to insulin resistance and β cell dysfunction.¹⁴ Data from the 2010 National Youth Physical Activity and Nutrition Study (NYPANS) revealed that 62.8% of high school students drank at least one sugar-sweetened beverages daily, and 32.9% drank two or more daily.¹⁵ The elevated consumption of these beverages not only affects the overall general health of adolescents in the form of increasing rates of obesity and diabetes but also has deleterious effects on the caries rates of adolescents.

Dental professionals should discuss both the dental and physical risks associated with excessive sugar-sweetened beverage consumption as part of their prevention program targeted toward adolescents. It is critical that this topic be discussed with the parents or legal guardians of those patients with special health care needs, because these individuals often possess obstacles that preclude the maintenance of adequate oral hygiene. The addition of sugar-sweetened beverages in such an oral environment places the special needs patient at risk for the development of rampant caries.

For the patient who has active lesions in the developing permanent dentition, dietary management and modifications are definitely indicated along with a comprehensive program of oral cleaning and daily topical fluoride use. Developing a complete understanding of the importance of this approach with the patient and determining his or her willingness to cooperate is critical to achieving a successful outcome. If the patient is interested and willing to cooperate, a dietary history is indicated. If not, it will be only a paper exercise and a waste of time for both parties involved.

Initially, a 24-hour dietary history will probably be sufficient. Based on the history and additional information from patients about their usual daily schedule and academic, athletic, and social obligations, the dentist or staff responsible for counseling can assist in devising a preventive plan with patients.

Having the patient acknowledge the problem and commit either orally or in writing to the recommended approach can often help improve compliance. During periodic examinations, the patient’s progress or lack of progress can be evaluated. Plans may have to be modified frequently depending on the patient’s changing needs. Because food preferences, social pressures, and growth changes occur frequently, this plan must allow for flexibility.

Although a 24-hour dietary history will be helpful, more insights can be obtained from a 5- or 7-day history that includes weekends. For improved accuracy, the patient should complete the first day’s record with the dentist, paying particular attention to all liquid and solid foods consumed both at meals and between meals. Information about how much of the food was consumed and where the food was eaten will be helpful.

Once the dietary history has been received, a staff person assigned to counseling responsibilities should carefully review it w/>

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