You Can Make a Positive Impact on a Child’s Oral Health! Oral Health Care for Very Young Children and Children with Special Health Care Needs Division of Dental Health Virginia Department of Health 109 Governor Street Richmond, Virginia 23219 804-864-7775 www.vahealth.org/dental 1

Kami A. Piscitelli, BSDH, RDH Special Needs Oral Health Coordinator Oral Health Care For Very Young Children and Children With Special Health Care Needs (CSHCN) For more information or to schedule an oral health presentation contact: Kami A. Piscitelli, BSDH, RDH Special Needs Oral Health Coordinator Division of Dental Health 804-864-7804 kami.piscitelli@vdh.virginia.gov Funded by Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services

What can you do? You’re already doing something! You’re here! You can make an impact by: Increasing your awareness of the oral health needs of children Promoting oral health to families of young children and CSHCN Encouraging age one dental visits 3

Topics Why oral health is important? What are the two most common dental diseases? The results of untreated dental disease Common dental problems of CSHCN Prevention of dental disease Visiting the Dentist

At what age should children start seeing the dentist?

Background Tooth decay is the most common chronic childhood disease. Tooth decay is 5 times more common than asthma; 7 times more common than hayfever. Approximately 28% of children ages 2-5 years old have tooth decay. CSHCN are almost twice as likely to have unmet oral health needs than children without SHCN.

Why is this important? They are only teeth!

The Function of Teeth Chewing / Digestion Speech Facial appearance Bone structure Confidence

Baby Teeth Are Important Too! Guide eruption of permanent teeth Healthy baby teeth = healthy permanent teeth

Baby Teeth

Oral Health Affects General Health In the Mouth Overall Health oral disease and infection systemic infection; can threaten life; unsuccessful organ transplant; surgery delay periodontal disease diabetes, bacterial pneumonia, low-birth weight, heart disease, stroke tooth decay malnutrition, failure to thrive, pain, loss of concentration, emotional/psychological stress malocclusion difficulty speaking/chewing, infections due to difficult oral hygiene

General Health Affects Oral Health Health Factors Oral Health gastric reflux / vomiting erosion of teeth, sensitivity medications reduced saliva, enlarged gums, decay special diets (soft, high carb) decay, periodontal disease oral habits trauma, injury chronic infections reduces ability to fight oral infections antibiotic therapy oral fungal infections physical abuse often seen as oral trauma Phenytoin, calcium channel blockers, cyclosporine – can enlarge gums Up to 50% of abused children suffer head and neck injuries, oral-lacerated frenums, scar tissue Genetic and developmental disorders: malocclusion, micrognathia, prognathia, delayed eruption, facial asymmetry

Two Most Common Dental Diseases ?

Two Most Common Dental Diseases Tooth Decay disease process also called Caries cavities are the result Periodontal “Gum” Disease Gingivitis Periodontitis

Early Childhood Caries (ECC) Definition: The presence of one or more decayed, missing or filled tooth surfaces in a child younger than six Begins soon after teeth erupt and can progress to a cavity in only 6-12 months Very quick, destructive form of decay Costly to treat Children have trouble cooperating because of age/condition Often requires oral sedation or general anesthesia

Factors Necessary for Tooth Decay 1. Bacteria: Streptococcus mutans 2. Food: fermentable carbohydrates (break down quickly) 3. Susceptible tooth 4. Exposure time This child is 1 ½ - 2 years old.

1. Bacteria Transmitted from parent to child, not born with it Infectious disease process Window of infectivity: highest in the first two years Early exposure to S. mutans is one of the major risk factors for future cavities Plaque: sticky film

Transmission of Bacteria Sharing of forks, spoons, straws Testing food temperatures “Cleaning” pacifier Pre-chewing food

2. Food: Fermentable Carbohydrates Simple or complex carbs: sugars, starches Bacteria uses the food to produce an acid Acid ‘demineralizes’ or eats away at the surface enamel, starting the disease process ‘White spot’ appears, normally at gumline

Snacks Foods low in sugar: Cheese Fruits Vegetables Cheerios, Rice Chex, Life, Kix, Corn Flakes Foods high in sugar: Candy Cookies Sodas Fruit drinks Sugar Smacks, Sugar Pops Approximately 4 Grams of sugar are in one teaspoon

3. Susceptible Tooth Susceptibility of the tooth is directly related to fluoride exposure What is Fluoride? a natural mineral found in ground water (wells) and surface water (lakes, ponds) fluoride is added to most community water supplies in Virginia for dental benefits tooth enamel ‘absorbs’ fluoride before and after eruption enamel is then more resistant to decay process

Fluoride Fluoride has several preventive effects Increases tooth’s resistance to cavities Encourages healing of new small cavities Prevents bacteria from making acid 2 categories of fluoride exposure Systemic (swallowed) – benefits teeth before and after they come in Topical – benefits teeth after they come in

Topical vs. Systemic Topical: outside the tooth / enamel Systemic: through bloodstream

Systemic (Swallowed) Fluoride Sources Water with fluoride (fluoridated water) Community water supplies Naturally occurring in well water Bottled water normally not fluoridated Water filters Fluoride prescription Prescribed based on results of water testing and other fluoride sources Drops, liquids, tablets (also topical benefits)

Topical Fluoride Sources Fluoridated water Fluoride toothpastes (ADA seal) Over the counter fluoride rinses Prescription supplements When chewed or liquid Professionally applied fluoride Gels, foams, rinses Varnish

Fluoride Varnish Safe and effective, 40-60% decrease in tooth decay Easy to apply Applied by nurses, doctors, dentists, and dental hygienists

4. Time (Acid Attacks) The more time teeth are exposed to the acids produced by the combination of bacteria and food, the more likely tooth decay will occur! (20-40 min acid attacks)

Results of Untreated Tooth Decay Unnecessary pain and discomfort Unfavorable treatment experiences Systemic (whole body) infections Premature loss of primary teeth Increased risk for permanent tooth decay Loss of school/work time Increased treatment expense

Periodontal (Gum) Disease Process 1. Plaque (bacteria) left on teeth and around gums 2. Gingivitis 3. Periodontal Disease

Gingivitis Irritation and inflammation of the gums Puffy, red gums that bleed easily Bleeding is not normal Signal to brush better Can be completely reversed and controlled with good oral hygiene

Periodontal (Gum) Disease Causes irreversible bone loss in the bone surrounding the teeth Leads to tooth loss Often completely painless, only a dentist or hygienist can detect the beginning stages Early stage treatment can stop or control the disease Later stages of the disease are much more difficult to treat

Periodontal Disease

Conditions Linked to Gum Disease Heart disease Stroke Diabetes Pre-term low birth weight babies Lung infections

CSHCN Common Dental Problems Bruxism: grinding/gritting teeth Wear/damage of teeth, TMJ disorders Older children may need a night guard Excessive drool Skin chaffing/rash, cracked/bleeding lips Use lotion, creams, lip balm Reflux/vomiting Erosion of teeth, increased cavities Use baking soda rinses ¼ - ½ tsp soda to 1 cup water

CSHCN Common Dental Problems Pouching: holding food in the folds of the cheeks Increased decay, periodontal disease, bad breath Frequent oral hygiene care Picking or poking at gums/teeth (source?) Trauma to teeth and gums Oral exam and behavior modification Xerostomia (Dry Mouth) Increased decay and mouth sores Saliva substitutes, sugar-free candy/gum – age?

Prevention Facts Preventing decay in primary teeth reduces risk in permanent teeth Preventing decay until age 4 reduces risk of decay through age 18

How can you prevent dental diseases? Positioning Lift the lip/ identify disease Oral hygiene Brush/floss Modifications Fluoride Nutrition Injury prevention Dental visits

Positioning at Home Positioning depends on each individual family and child Head in your lap Standing with you behind supporting head Bean bag or pillows Child sitting on floor and you sit in chair right behind Knee to knee when two adults available Be careful of tilting head too far back if there is difficulty swallowing or gagging or neck injury concern

Lift the Lip Get to know your child’s mouth Early decay is most commonly found on the lingual (back) surfaces of the front teeth. Abscesses (infections) can hide from you

Disease Identification Identify “White Spot” Pre-decay and active decay

Disease Identification

Disease Identification

Disease Identification

Disease Identification

Disease Identification

Disease Identification Periodontal (Gum) Disease Gingival overgrowth Fungal/Viral Infection

Brushing the Teeth Infants (less than 2 years old) Gums should be wiped twice daily When teeth erupt, brushed twice daily Use a rice grain sized amount of fluoride toothpaste Toddlers and Preschool (older than 2 years) Brush teeth at least twice daily Use pea sized (or a kernel of corn sized) amount of fluoride toothpaste Parent supervision and help with brushing until age 7-10 years Depends on skill level of the individual child

How To Brush Use clean hands Use a soft bristled brush Brush the front, back, & biting surfaces of each tooth Use same pattern each time so you don’t miss teeth Angle the brush toward the gums and brush with a circular motion Include gumline and tongue

Brushing Tips If unable to spit, wipe with damp or dry clean cloth Change toothbrush every 3 months or when bristles look out of shape If child doesn’t tolerate toothpaste, try dipping brush in an over-the-counter fluoride mouth rinse (like ACT) then brush Let the child be as independent as possible, use the toothbrush themselves, then you brush as well

How To Floss Flossing begins as soon as the sides of two teeth are touching Most children cannot floss on their own until 8-10 years, some CSHCN may need flossing done for them Work the floss back and forth gently between teeth Curve floss around the side of each tooth sliding up and down, just under the gums Floss both sides of every tooth Ask a dentist or hygienist for help

Flossing

Oral Hygiene Modifications Toothbrushes and floss may need modification for CSHCN Battery operated toothbrushes Modified toothbrush handles Tennis ball or bicycle grip Taped handles Lengthen by taping to ruler Bend toothbrush handle by heating handle under hot water Secure toothbrush to the hand with Velcro strip Use bigger or textured grips Three sided toothbrush heads Floss holders Mouth Props

Fluoride Recommendations Use fluoride toothpaste for all ages Talk to the dentist about increasing topical fluoride Fluoride mouth rinse – brushed on or swished if they can spit out the excess Prescription fluoride gel brushed on Professional fluoride treatments more often

Feeding / Nutrition Begin use of training cup by six months if developmentally able Use training cups carefully and temporarily Mealtime only if milk, juice, or sweet drink Not walking around with cup Between meals – offer water only Talk to physician or pharmacist about sugar free medicines Well balanced diet

Dental Injury Prevention Things to avoid: Sharp edges on furniture – cover if possible Walking or running with hard or sharp objects in mouth (sippy cup, toothbrush, crayons, etc.) Chewing on electrical cords Chewing on ice, hard candy, any hard objects Riding in the car without a car seat Mouth guards and helmets as needed

Dental Visits: “Home by One!” Dental appointment by the first birthday CSHCN may need to visit dentist every 2-6 months Tell dentist what works and doesn’t work at home Bring a favorite blanket, toy, music, etc. Encourage a consultation between your physician and dentist

Finding A Dentist DentaQuest (formerly DORAL): Smiles for Children www.dmas.virginia.gov/dental-home.htm Some listings will specify special needs: yes/no Phone book, word of mouth, parent organizations When you call, ask if the dentist will see children with the particular condition the child has

Finding A Dentist VA Department of Health, Division of Dental Health www.vahealth.org/dental/ Virginia dentist directory – click on “Find A Dentist”

Click here to find a dentist Click here to find more oral health information on CSHCN

Click Advanced Search for the most options

Click here when you have made your selections

Click on the dentist’s name for more information then call the dentist’s office to describe your needs and ask questions

Resources for More Information American Academy of Pediatric Dentistry www.aapd.org American Academy of Pediatrics www.healthychildren.org – type in ‘oral health’ American Dental Association www.ada.org The Center for CSHCN, Washington State www.cshcn.org – type in ‘oral health’

Additional Resource http://hfgrotto.org/ Financial assistance for dental care for children with disabilities under age 18 with Cerebral Palsy, Muscular Dystrophy (and related neuromuscular disorders), mental retardation, and organ transplant recipients.

Key Points Oral health is directly related to overall health Preventing decay in primary teeth reduces risk in permanent teeth The more time teeth are exposed to acids the more likely tooth decay will occur! Dental home by age one Fluoride is important for all ages

Questions???????