Tobacco and Electronic Cigarettes

Tobacco use remains the leading cause of preventable disease and death in the US. ^, Tobacco use is most commonly adopted during adolescence, when the brain is most vulnerable to nicotine addiction and when life-long habits are likely to be formed. ^, Therefore, it is important to recognize and address the detrimental impact that tobacco use can have on an adolescent’s oral and general health. ^, Research has shown that 90% of adults who smoke cigarettes daily tried their first cigarette before the age of 18 years. Although the current use (ie, within the past 30 days) of any tobacco product among middle and high school students decreased from 2017 to 2019, there were still almost 4.5 million youth tobacco users in 2020. Ubiquitous advertising and influence of social media make adolescents more likely to try new and traditional tobacco products.

Tobacco products used by adolescents include cigarettes, electronic cigarettes (e-cigarettes), cigars, smokeless tobacco, heated tobacco products, hookah, and pipe tobacco. The current use of cigarettes among middle and high school students has decreased over the past 9 years. In 2020, 6.2% of them reported current cigarette use, down from 15.1% in 2011. It is predicted that if cigarette smoking among young people continues at the current rate, 5.6 million US youth will die early from a smoking-related illness. Since 2014, e-cigarettes (“vaping”) have been the most common tobacco product used by adolescents in the US, especially with the availability of multiple flavors. In 2020, 24.3% of middle and high school students reported current e-cigarette use, but it was down from 38% in 2019, when vaping among adolescents increased dramatically. ^, After e-cigarettes, the next most commonly used tobacco product by young students is cigars. In 2020, 6.5% of them reported current cigar use, which was 8.6% less than what they reported in 2011. Smokeless tobacco use by youth has also decreased over the past 9 years. In 2020, only 4.2% of middle and high school students reported current use, down from 10.1% in 2011. Almost 3% of those students reported current use of heated tobacco. Hookah was the only product that showed no decrease in current use among students from 2011 to 2020 (5%). Pipe tobacco was the least used tobacco product by youth in 2020 (1.1%).

Many young people use more than two tobacco products, making them more likely to develop nicotine addiction and more likely to continue use well into adulthood. ^, In 2020, 11% of middle and high school students reported current use of two or more tobacco products. ^, Numerous factors influence the use of tobacco products during adolescence, including the physical and social environment in which they reside. Youth living with parents who use tobacco, those with friends who use tobacco products, and high school athletes are more likely to use these products than their peers. ^{, ,} Youth are also more likely to use tobacco products if they are from lower socioeconomic status households, have caregivers who are less attentive or supportive, have low self-esteem, and if they suffer from mental health issues, such as anxiety, depression, and stress. ^{, ,} Therefore, it is extremely important to develop targeted interventions that will reduce and prevent the use of tobacco products among adolescents.

Oral health implications

The use of tobacco can have both short and long-term adverse effects on oral and systemic health. Cigarette smoking has been linked to about 90% of all lung cancer cases, the leading cause of cancer-related death in both men and women. Tobacco use is also associated with oral cancer, cancer of the pharynx, larynx, esophagus, stomach, pancreas, cervix, kidney, and bladder. The use of tobacco drastically increases the risk for pulmonary and cardiovascular diseases, such as coronary heart disease, which is the leading cause of death in the US.

All forms of tobacco currently available on the market have oral health consequences. Smoking cigarettes can lead to gingival recession, impaired healing after periodontal therapy, periodontal disease, mucosal lesions, tooth staining, and oral cancer. ^, Smokeless tobacco can cause gingival keratosis, gingival recession, periodontal disease, tooth loss, halitosis, alveolar bone damage, and dental caries because of sugars that may be added to the products. ^, Nicotine, the primary addicting component of tobacco products, can also lead to local burning sensation, throat irritation, dry lips, and ulcerations.

Illicit Drug Use

National US surveys show that most adolescents engage in some form of substance use during high school. Illicit substance use in adolescence is strongly associated with misuse by friends outside school, boyfriend/girlfriend, siblings, and online friends, which shows the impact of peer influence. Besides that, other risk factors for illicit drug use include social disadvantages, limited parental monitoring, parental substance use, impulsive personality, poor school performance, easy access to alcohol and other substances, and affiliation with delinquent peers. ^, The progression from alcohol and tobacco to cannabis and later to other illicit substances is clear. ^, In the US, legalization of medical marijuana in certain states has led to more use of crack/cocaine and heroin by youth.

The past decade saw a decrease in alcohol consumption by US youth but increased use of e-cigarettes, marijuana, and opioids. The 2009 to 2019 survey of substance use behaviors of US high school students also showed a decrease in the prevalence of lifetime use of marijuana, cocaine, methamphetamine, heroin, synthetic marijuana, and injection drug use. Of particular concern are the lifetime rate (1 in 7 adolescents) and current prevalence (1 in 14) of opioid misuse; those students also showed high rates of misuse of other substances. In 2019, 29.2% of students used alcohol, 21.7% consumed marijuana, 13.7% reported binge drinking, and 7.2% misused prescription opioids. Boys had a higher prevalence of lifetime use of cocaine, methamphetamine, heroin, and injection drug use while girls abused alcohol and prescription opioids more often. Black and Hispanic students misused prescription opioids more frequently than whites, who had a higher prevalence of alcohol consumption. Lesbian, gay, and bisexual students had a higher prevalence of all substance use behaviors, except binge drinking, compared with heterosexual students.

Cannabis is a broad term used to describe the different products, such as marijuana and cannabinoids, that are derived from the cannabis sativa plant. Its use has increased in recent years, possibly due to the legalization in certain states and the rise in its social acceptance. Historically, cannabis had been smoked as marijuana; however, it has become increasingly available in a variety of forms, including edibles and topically applied products. Although recreational marijuana use by adolescents is not legal in any US state, they continue to use it, under the perception that it is safer than alcohol and other drugs. There are no significant differences in marijuana used based on gender, race/ethnicity, grade in school, or sexual identity. ^,

Frequent cannabis use has been associated with chronic systemic health effects, including addiction, difficulty thinking and problem solving, problems with memory, and impaired coordination. ^, It may also be associated with psychotic disorders and an increase in psychotic symptoms. Cannabis contains many of the same carcinogens as tobacco, therefore repeated use can also lead to cardiovascular and respiratory pathologies. With the documented detrimental effects that cannabis can have on the adolescent brain and other body systems, it is imperative that dental professionals participate in the provision of anticipatory guidance to help decrease its use among this population.

Abuse of cannabis rarely leads to death, in contrast to opioids and other illicit drugs. These substances can also cause mental health issues, chronic health problems, and high-risk behaviors that can lead to pregnancy, sexually transmitted diseases (STDs, such as human immunodeficiency virus [HIV], human papillomavirus [HPV], etc.), exposure to coronavirus, motor vehicle accidents (MVAs), suicidal ideation, homicides, and violence. ^,

Oral health implications

The use of cannabis, particularly marijuana smoking, is associated with poor oral health; however, determining the etiology of the oral health problems can be complicated because of additional risky behaviors of those who are frequent users. Adolescents who engage in marijuana use may also use tobacco, alcohol, and other illegal substances, which have their own oral health consequences. Cannabis use has been linked to xerostomia, thus it contributes to an increased caries incidence. Cannabis can also be an appetite stimulant, leading to higher consumption of foods and snacks that may be cariogenic. ^, This can be particularly detrimental during adolescence, when patients are also more likely to be inattentive to oral hygiene practices, have heightened caries experience, and gaps in oral health care access.

Smoking marijuana is also associated with gingival enlargement, erythroplakia, chronic inflammation of the oral mucosa with hyperkeratosis, and leukoplakia, which has the potential to become malignant. Cancer associated with cannabis use is more aggressive in younger users, and those who use both tobacco and cannabis are at an increased risk for oral and neck cancer. ^{, ,} Cannabis use has been linked to periodontal disease, with higher rates of periodontitis being observed among frequent users than nonusers. ^, Chronic periodontitis may occur at an earlier age in marijuana users, which is especially important to note when counseling adolescents about marijuana use.

Patients on cannabis may also present behavioral challenges for the dental provider. Cannabis use can cause anxiety, paranoia, hallucinations, and hyperactivity, which can make patients more stressed during their dental appointments. ^{, ,} It can also cause increased heart rate and other cardiac effects that could make the administration of local anesthesia with epinephrine and other anxiolytic agents potentially dangerous. ^{, ,} Patients, especially those who are under the legal buying age, may be unwilling to self-report cannabis use; therefore, it is important that dental providers are aware of the signs and symptoms of cannabis use. Owing to the risk of medical emergencies when treating intoxicated patients, practitioners should postpone nonemergent treatment in those situations.

To prevent misuse of prescription drugs by youth, dentists must reduce the number of prescriptions and the amount in the prescription as well as participate in prescription drug monitoring programs. ^, They must also consider the drug-seeking behavior of addicted legal guardians who may use the adolescent to obtain prescription drugs for their own use. Illicit substances can also interact with general anesthetics; thus, careful preoperative evaluation is crucial for safe delivery of care and alleviating the effects of drug withdrawal. ^, Other harmful effects of illicit drugs in the oral cavity include bruxism, tooth wear, lip paresthesia, ulcers, trismus, and temporomandibular joint dislocation. To alleviate xerostomia, many individuals use soft drinks or sports drinks to quench their thirst, increasing their caries and dental erosion risk. These patients should receive supplemental fluoride in the form of mouth rinses, toothpastes with high concentration of fluoride and more frequent professional applications.

Driving and Sports Safety

Adolescent driving

MVAs are the second leading cause of death for teens in the US. In 2018, 2500 teens aged 13 to 19 years were killed and 285,000 were treated in emergency departments for injuries suffered as a result of MVAs. Individuals aged between 16 and 19 years were almost 3 times more likely to be involved in a fatal crash than those aged more than 20 years. Men, teens driving with other teen passengers in the car, and newly licensed teens are at especially high risk for motor vehicle crashes. In 2019, 2,375 teenagers aged 13-19 years died in a car crash; 2 out of 3 were males.

Seat belt use is essential to prevent casualties from MVAs; however, teens and young adults have the lowest seat belt use rates. In 2019, 43% of high school students in the US reported they did not always wear a seatbelt when riding with someone else. In 2019, half of teenage drivers who died in a car crash were not wearing a seat belt. Driving while distracted, such as sending a text message, talking on the telephone, using a navigation system, and/or eating, also puts young drivers at higher risk for MVAs. In 2019, 39% of high school students who drove in the past 30 days texted or emailed while driving on at least 1 day. Those who texted and emailed while driving were also more likely to report they did not wear a seatbelt, were more likely to ride with a driver who had been drinking alcohol, and more likely to drive after drinking alcohol.

Drinking any amount of alcohol before driving also increases accident risk among teen drivers. ^, In 2019, 5.4% of driving high school students reported that they had been drinking alcohol at least once before driving within the previous 30 days. Drinking and driving were higher for students who were older, men, Hispanic, and with lower grades. Students who engaged in other transportation risk behaviors (ie, speeding, distracted driving, etc.) were up to 30 times more likely to drive after consuming alcohol. Teen drivers have a much higher risk for being involved in a crash than adult drivers with the same blood alcohol concentration (BAC). They are also more likely to be involved in accidents when they have BAC levels below the legal limit for adults.

Speeding also puts adolescent drivers at higher risk for MVAs. In 2018, 30% of male drivers and 18% of female drivers aged between 15 and 20 years who were involved in fatal crashes were speeding. Teen drivers are more likely to speed in general and less likely to keep the appropriate distance between cars while driving compared with older drivers.

The adolescent athlete

It is important that caregivers and adolescent athletes recognize the risk of participating in sports as well as the importance of taking the appropriate safety measures to prevent injury. Besides preventing trauma to the oral cavity during athletic activities, caregivers and medical/dental providers must also be aware of other risky behaviors in which the adolescent athlete might engage. For example, they may strive to achieve optimal weight and physical qualities to make them competitive, which could cause disordered eating and eventually an eating disorder. The prevalence of disordered eating and eating disorders in adolescent athletes is high, especially those competing in weight-sensitive sports. This frequently occurs because of the desire to achieve the “ideal” body and to alleviate body dissatisfaction.

Adolescent athletes are also likely to drink alcohol, use tobacco, steroids, and other performance-enhancing substances. Highly active athletes are more likely to drink excessively than their peers, especially male athletes. Early use of steroids and other performance-enhancing substances are also an area of concern. This is most commonly seen in men and non-Hispanic whites, and tends to occur earlier in athletes than their peers. Steroid use also varies based on the type of sport, being more common among those involved in strength training sports like gymnastics and football. Youth participation in sports has been associated with higher odds of binge drinking and e-cigarette smoking, but with lower odds of cannabis and cigarette use. ^, Young cigarette smokers tend to be more sedentary than e-cigarette users.

Athletes, their families, and athletic personnel must also be aware of the proper safety measures and management protocols related to concussions. Sport-related concussions can interfere with schoolwork, social interactions, and prevent participation in sports. If undiagnosed and/or untreated, long-term cognitive impairments may occur.

Oral health implications

Orofacial trauma can be an outcome of MVAs and sport-related accidents. In addition to medical assessments and treatment, individuals involved in any type of accident should be evaluated for possible dental, oral, and facial bones–related injuries. Medical and dental providers must be aware of the protocol for the management of dental trauma and should treat emergent cases and/or make referrals to other specialists, especially in cases involving craniofacial structures other than the teeth.

Although physical injury during MVAs and sports accidents may be inevitable, taking the necessary precautions, such as wearing seatbelts and protective sports equipment (mouth guards, helmets, etc.) is of great importance. Traumatic dental injuries resulting from participation in sports as well as in leisure activities, such as skateboarding, roller-skating, and bicycling, have been significantly decreased by wearing well-fitting mouth guards and protective equipment. When accidents do occur, timely management of orofacial trauma is very important, as the long-term effects can lead to prolonged treatment needs, difficulties with speech, eating, and a negative impact on oral health-related quality of life.

Disordered eating, eating disorders, and use of tobacco cause negative impacts on oral health, which have been discussed in this and other articles in this issue. Athletes may also attempt to maintain proper hydration by consuming isotonic beverages, which can increase caries risk because of high sugar content and cause enamel erosion because of their acidic pH. There is also a connection between enamel erosion and prolonged exposure to chlorinated swimming pool water in competitive swimmers. Therefore, dental professionals must give clear recommendations to athletes to prevent dental trauma, caries, and erosion.

Alcohol Use

Alcohol was the most frequently used substance by US high school students in 2019 (29.2%). The prevalence of current alcohol use was higher for women, and for white (34.2%) and Hispanic students (28.4%) more than black students (16.8%). Several factors may lead an adolescent to early alcohol use. Regular smoking and social anxiety disorder are known predictive factors for early use of alcohol. Parental alcohol use disorder (AUD) is also a consistent predictor of increased early use of alcohol, cannabis, and sexual initiation of their offspring. In addition to that, adolescents’ exposure to alcohol on media and other means (eg, movies) is correlated with their initiation of drinking alcohol as well as increased drinking among those already using it. Most importantly, early initiation of alcohol use, including binge drinking and heavy drinking, predicts AUD later in life. ^{, ,}

Binge drinking is defined as alcohol consumption that raises the BAC to at least 0.08% (ie, 5 drinks for men and 4 for women within 2 hours), whereas heavy drinking uses the same criterion but in a higher frequency (5 or more days in the last 30 days). Binge drinking is the most common pattern of alcohol consumption in adolescents and young adults, being reported by 13.7% of US high school students in 2019, with women showing substantially higher rates than men (31.9% vs 26.4%). Both binge and heavy drinking cause neurobiological changes, affecting brain responses in several regions while performing a variety of tasks, including risky decision-making (eg, having unprotected sex, driving after drinking, using illicit substances, etc.) and reward response. It may also lead them to more exposure to the current coronavirus.

Changes in alcohol consumption among college students because of the COVID-19 pandemic have been documented. College students who moved from living with peers to parents showed greater decrease in drinking days, number of drinks per week, and maximum drinks in 1 day than those who remained living with friends or were already living with parents. Thus, returning to live with parents during early adulthood may be protective against heavy drinking.

Oral health implications

The increased risk for oral diseases in individuals who abuse alcohol depends on their age and the length of alcohol addiction. A Ukrainian study found that the prevalence rate of oral diseases for 14- to 17-year-old individuals who had been abusing alcohol for 2 years was 10.9%, and 16.8% for those who had abused it for 3 years. Thus, assessment of the oral status in young alcohol abusers is of great clinical significance for early detection of diseases of the oral mucosa, including potential precancerous lesions.

The cytotoxic effect of alcohol is among the leading causes of malignant degeneration of the oral mucosa. The toxic effect of ethanol and/or its metabolite acetaldehyde on the oral mucosa results in increased cell regeneration that may play an important role in tumor promotion. Chronic ethanol consumption causes oral mucosa atrophy, which may result in an enhanced susceptibility of the mucosal epithelium to chemical carcinogens, thus creating a major risk factor for oral and pharyngeal cancer. Alcohol breaks down into acetaldehyde, which can bind to the proteins in the oral cavity triggering an inflammatory response in the body, causing the development of cancerous cells.

Alcohol consumption is associated with increased occurrence of periodontitis due to impairment of neutrophil function, leading to bacterial overgrowth that may cause periodontal inflammation. ^, In addition to that, alcohol may have a toxic effect on periodontal tissue and may increase monocyte production of inflammatory cytokines in the gingival crevice, which is associated with periodontitis and attachment loss.

Features suggestive of alcohol misuse include missed dental appointments, alcoholic breath, parotid gland enlargement, glossitis, loss of tongue papillae, spider angiomas, and angular cheilitis caused by malnutrition. ^, Teens who abuse alcohol also tend to present with more dental trauma. ^, The dental professional should stress the importance of daily oral hygiene and a healthy diet as they are not usually a priority for these patients. Invasive dental procedures should only be done when the individual is stable. Consultation with the patient’s physician is a necessity to discuss drug selection and administration as well as potential bleeding tendencies.

The use of a single alcohol screening question is ideal for the dental practitioner because it is simple and not time-consuming. Providers should ask male patients if they have consumed 5 or more standard drinks on one occasion in the past year (4 drinks for a woman). A positive answer may indicate an alcohol problem, requiring a more detailed evaluation by the primary care physician.

Internet Addiction, Internet Gaming Disorder, and Gambling

Internet addiction, IGD, and gambling are growing concerns related to risky behaviors in adolescence. Internet addiction and problematic Facebook use are significant global problems that can lead to somatic and mental symptoms, such as depression, psychoticism, paranoid ideation, suicidal ideation and attempts, anxiety, and serious mental illness. It has also been linked to withdrawal from sports and clubs, alcohol abuse, attention deficit, and hyperactivity. ^, However, some authors consider excessive use of the Internet as a symptom of mental health problems rather than a cause.

The fifth version of the Diagnostic and Statistical Manual of Mental Disorders added IGD, which also includes non-Internet gaming sources, as a potential new diagnosis because heavy gaming can cause psychosocial and medical problems. Risk factors for IGD include male sex, young age, and psychological symptoms, such as depression and social isolation. Gaming is particularly attractive to those in social isolation or with poor interpersonal skills because it allows them to develop online relationships and assume new personalities. Impulsivity has also been linked to IGD and can lead to risky behaviors, such as smoking, drug use, and violence. ^, Excessive gaming may also alter the brain in a way that it increases the risk of depression and aggressive behavior. In addition to that, pathologic video game use can lead to poor school grades and attention problems. Students who are heavy Internet users, whether they are gamers or not, show similar higher risks for emotional problems, conduct disorder, hyperactivity, inattention, self-injurious behaviors, and suicidal ideation.

Social media also seems to be a major global influencer on youth gambling. A strong sense of belonging to an online community is associated with higher problem gambling, especially if adolescents are involved in social media identity bubbles. Regular gambling by adolescents and young adults has been associated with parental gambling behavior, maternal educational background, cigarette smoking, misuse of alcohol, illicit drug use, suicide attempts, and fighting. Other risk factors include male sex, low educational attainment, low socioeconomic status, unemployment, sensation seeking, cyberbullying, and delinquency. Problematic gambling also includes lottery games, scratch cards, card games, and sports betting.

Oral health implications

There are no studies to date linking specific oral health issues to Internet addiction, gaming, and gambling. However, as these adolescents may develop psychological issues that can lead to risky behaviors and sensation seeking, there is a potential for behavioral problems in the dental office as well as oral manifestations of substance use and STDs. Furthermore, these adolescents may not prioritize diet and oral hygiene, which may lead to increased risk for obesity, caries, and periodontal disease.

Human (Adolescent) Trafficking

Human trafficking includes sex trafficking, labor trafficking (domestic work, agriculture, farming, etc.), or sex and labor trafficking combined (prostitution, working in bars and strip clubs, etc.). Adolescent sex trafficking is defined as the recruitment, harboring, transportation, provision, obtaining, patronizing, or soliciting of a minor for the purpose of a commercial sexual act. No youth is safe from becoming a trafficking victim, regardless of race, age, socioeconomic status, or location (urban, suburban or rural, or country of origin). ^, International victims usually come from countries torn by poverty, or political and economic instability.

The United States has a homegrown problem of youth being exploited for commercial sex. Adolescents who come from poor or minority families, runaways, those involved with the child welfare system or juvenile justice, victims of physical abuse, sexual abuse or abandonment, undocumented immigrants, and those addicted to drugs and/or alcohol are the typical targets of pimps and traffickers. ^{, ,} Other risk factors include having family members in sex work and having friends who sold or bought sex. Pimps and traffickers attract victims with offers of food, shelter, employment, love, friendship, nice clothes, jewelry, and a better life prospect, moving them away from families and friends. ^, They use emotional, physical, and psychological abuse to keep victims trapped in a life of prostitution or forced labor. Eventually, these adolescents will suffer from depression, feelings of hopelessness, and low self-esteem.

Health care providers, including dental professionals, frequently overlook or fail to identify trafficked youth, resulting in continued perpetration of crimes against them. One of the reasons is their lack of education and comfort in discussing the topic. Stereotypes may also prevent them from recognizing as victims patients who are already under their care, such as US citizens, those from high socioeconomic classes and boys. However, recognizing trafficking victims can be challenging. Some red flags include individuals who lack proper documentation; who lie about their age; who are accompanied by someone who is older, not a relative or legal guardian (eg, boyfriend), and/or who is very controlling and does not leave the person alone; those who give inconsistent histories to explain their health condition or chief complaint; individuals who do not have a medical or dental home; who wear expensive clothing and jewelry that do not seem appropriate; and who carry large amounts of cash. ^, Many victims do not self-disclose even if they have the opportunity, fearing for their safety and that of family members, or because they feel ashamed or hopeless about their situation. ^{, , ,} Observing the patient’s body language and other visual cues, as well as their communication style and that of the accompanying person, can aid in the identification or suspicion of victims.

Oral health implications

One important aspect of providing health care to individuals involved in traumatic situations, such as sexual abuse and trafficking, is through trauma-informed care (TIC). TIC is defined as “understanding, respecting, and appropriately responding to how human trafficking and other types of trauma affect a survivor’s life, behavior, and sense of themselves.” That means providing a safe environment for the patient (trained staff on the issue, confidentiality, reporting procedures, etc.), using an interpreter other than the person accompanying the patient, trying to provide a private environment for interviews and treatment (separate the patient from the accompanying person), and being aware of how medical and dental care can retraumatize a victim, among others. The dentist, or any auxiliary staff, may be able to separate the patient from the accompanying person by taking the patient away for a radiograph or simply stating that office policy dictates that the examination be done privately. If the dentist believes the patient is a trafficking victim, the National Human Trafficking Resource Center hotline (1-888-373-7888) can be contacted for help. If the victim refuses assistance, the provider should give him/her the hotline number and in case of minors, a report must be filed with the child protection services.

The trafficking victim may have dental and oral problems because of neglect and/or dental trauma. The oral health professional must take a detailed health history, particularly concerning STDs, mental health issues (post-traumatic stress disorder, anxiety, substance abuse, panic disorder, depression, etc.), tuberculosis, malnutrition, pregnancy, and physical injuries. ^, Trafficking victims may also be more exposed to the novel coronavirus and have less access to testing and treatment.

Sexual Behavior

Preventing unintended pregnancy and STDs among adolescents is a public health priority. In 2015% to 2017%, 42% of female teenagers and 38% of male adolescents in the US were sexually active, with non-Hispanic black male teens showing higher rates of sexual activity than Hispanics and non-white Hispanics. Condoms are the most commonly used contraceptive method among US teens (97%). Other frequently used methods include withdrawal (65%), oral contraceptives (53%), long-acting reversible contraception (20%), and emergency contraception (19%). Non-white Hispanics presented higher percentages of using any contraceptive method than Hispanics and blacks. In the US, there is greater reliance on condom use and withdrawal than other contraceptive methods because adolescents either do not have health insurance or are covered by their parents’ insurance plan, leading to confidentiality issues.

There is a growing concern about the increase in the prevalence of STDs in adolescents, specifically between 15 and 19 years of age. Several factors account for the increase—teens are more likely to engage in high-risk sexual behavior, less likely to use sexual health services, whereas female teens have lower production of cervical mucous and increased cervical ectopy, which facilitates the development of STDs. One in four sexually active female teenagers aged between 15 and 19 years in the US has an STD, especially chlamydia and HPV. These diseases can cause chronic health problems if not treated early or if left untreated. They can lead to nervous system and cardiovascular system damage (due to tertiary syphilis), adverse birth outcomes and infertility (gonorrhea), cervical, oropharyngeal and rectal cancers (HPV), and acquired immunodeficiency syndrome (HIV). The HPV vaccine introduced in 2006 has led to a 64% reduction in HPV prevalence among women from 14 to 19 years of age and became a critical component of teenage sexual health due to high vaccine effectiveness. HPV vaccine is recommended for 11 and 12-year-old boys and girls, with catch-up vaccination up to 26 years of age.

Adolescents are more likely to engage in oral sex than intercourse, report more oral sex partners than intercourse partners, and unlikely to use STD protection during oral sex, ^, which has led to a significant increase in the prevalence of genital HSV-1. ^, Other populations at high risk for STDs include homeless, incarcerated or drug-using youth.

Another significant concern is an unplanned pregnancy. In the US, the number of births to teen mothers has dropped steadily since 1990, declining 45% from 2001 to 2013. In 2018, just under 180,000 infants were born to 15- to 19-year-old teens. This lower trend has been driven both by fewer teenagers having sex and more birth control use. ^{, ,}

Oral health implications

Screening and examination for oral signs of STDs and appropriate referral by the dental provider are important because STDs frequently affect the mucous membranes producing characteristic lesions on the oral mucosa. HPV can affect the mouth and throat, and some high-risk strains, particularly HPV-16, are associated with cancers of the head and neck. ^{, ,} These cancers are four times more common in men than in women and tend to develop at the base of the tongue, in the folds of the tonsils or the back of the throat, making them difficult to detect. ^, Low risk strains of HPV may cause warts or lesions in the mouth or throat. ^, Aside from their appearance, they often have very few symptoms, which are painless and noncancerous. They can reappear from time to time, and they should be surgically removed. Therefore, dental professionals are in a unique position to discuss HPV prevention and vaccination with their patients and parents.

There are two strains of HSV and there is no cure for either one. HSV-1 is most commonly associated with cold sores and other oral lesions, whereas HSV-2 is associated with genital lesions. Both strains are extremely contagious and can be passed between the genitals and the mouth through saliva and contact with open sores during and right before an outbreak. During an outbreak, blisters will appear in the mouth, which generally heal within 7 to 10 days. Analgesics can be prescribed to reduce fever and pain and antiviral drugs, such as acyclovir and valacyclovir, can be effective for the treatment of herpes as well as cold sores.

Syphilis may appear as sores (chancres) on the lips, tip of the tongue, gingiva, or at the back of the mouth near the tonsils in the first stages of infection. They start as small red patches and grow into large open sores that can be red, yellow, or gray in color, which are very contagious and often painful. Although oral manifestations can be observed at the primary stage, they are more commonly detected at the secondary stage as multiple painless ulcers with irregularly shaped whitish edges on the oral mucosa, tongue, lips, and buccal mucosa. The sores may resolve even if untreated, but the individual still may have syphilis and can infect others. The dental provider can do a biopsy to confirm the diagnosis. If positive, a referral to the patient’s primary care physician for more testing and treatment should be done.

Gonorrhea is a bacterial infection that affects mucous membranes, including those in the mouth and throat. It can be difficult to detect because its symptoms are often very mild and can go unnoticed. The most common oral symptoms are soreness or burning in the throat, but swollen glands and occasionally white spots in the mouth might also occur. Pharyngitis is often asymptomatic but may manifest with an exudative sore throat. A throat culture swab test can diagnose gonorrhea if symptoms in the mouth are present.