1. ESTABLISHMENT OF A DENTAL HOME FOR PEDIATRIC DENTAL PATIENTS Dr. Lisa Jacob Chief of Pediatric Dental Medicine Dell Children’s Medical Center Austin, TX

2. Early Early Detection __ Infants be evaluated by a dentist within 6 months of eruption of their first tooth and no later than 12 months __ Allows a dentist to assess a child’s risk of developing caries __ Counsel parents and caregivers about what they can do to reduce risk © Lisa S Jacob, DDS, MS 2009

3. Goal  Establish an ongoing relationship between dentist and the patient, inclusive of all aspects of oral health care, delivered in a comprehensive continuously accessible, coordinated and family centered way © Lisa S Jacob, DDS, MS 2009

4. Dental Home D0145- Oral evaluation for a patient under three years of age and counseling with primary caregiver D0145- Oral evaluation for a patient under three years of age and counseling with primary caregiver Goal: To prevent dental problems Goal: To prevent dental problems © Lisa S Jacob, DDS, MS 2009

5. First Dental Home Visit 1. 1. Review of Dental and Medical history 2. 2. Comprehensive oral examination 3. 3. Caries risk assessment 4. 4. Application of topical fluoride varnish 5. 5. Dental prophylaxis 6. 6. Oral hygiene instructions with primary caregiver 7. 7. Dental anticipatory guidance 8. 8. Establishment of recall schedule © Lisa S Jacob, DDS, MS 2009

6. Why complete a caries risk assessment? Determine potential for development of Severe Early Childhood Caries by identifying: √ Oral Health Status √ Potential transmission sources Direct dental anticipatory guidance content Determine an appropriate recall periodicity schedule for the child © Lisa S Jacob, DDS, MS 2009

7. Caries Risk Assessment Tool (CAT) 2002- American Academy of Pediatric Dentistry (AAPD) adopted CAT for infants, children, and adolescents 2006 AAPD revised the CAT AAPD encouraged both dental and non-dental health care providers to use the CAT Clinicians had to perform an adequate visual examination of the child’s teeth and mouth © Lisa S Jacob, DDS, MS 2009

9. Risk factors to consider History Determined by interviewing the parent/primary caregiver Clinical evaluation Determined by examining the child’s mouth Supplemental Professional Assessment Optional © Lisa S Jacob, DDS, MS 2009

10. High caries risk patient Each child’s overall assessed risk for developing decay is based on the highest level of risk indicator Each child’s overall assessed risk for developing decay is based on the highest level of risk indicator Single risk in any area of the “high risk” category classifies a child as being “high risk” © Lisa S Jacob, DDS, MS 2009

11. Child’s use of dental home Frequency of dental visits Never :High risk Irregular: Moderate risk Regular: Low risk http:// www.ardentoys.co.uk/images/uploads/bay-tree-house2.jpg © Lisa S Jacob, DDS, MS 2009

12. Child has decay Yes: High risk No: Low risk www1.istockphoto.com/file_thumbview_approve/1609464/2/istockphoto_1609464_uh_oh_a_cavity_vector.jpg © Lisa S Jacob, DDS, MS 2009

13. Patients with special needs Especially those that impact motor coordination or cooperation Ectodermal dysplasia Dental enamel is not well mineralized Newbrun E. Current treatment modalities of oral problems of patients with Sjogren’s syndrome: caries prevention. Adv Dent Res. 1996: 10; 20-34. Newbrun E. Current treatment modalities of oral problems of patients with Sjogren’s syndrome: caries prevention. Adv Dent Res. 1996: 10; 20-34. © Lisa S Jacob, DDS, MS 2009

14. Parent’s socioeconomic status Low SES: High risk Midlevel SES: Moderate risk High SES: Low risk http://library.thinkquest.org/J003358F/money_tree5.jpg © Lisa S Jacob, DDS, MS 2009

15. Impaired saliva composition/flow Long-term doses of medications can increase caries risk Long-term doses of medications can increase caries risk Impaired salivation High mineral loss Bardow A, Nyvad B, Nauntofte B. Relationships between medication intake and complaints of dry mouth, salivary flow rate and composition, and the rate of tooth demineralization in situ. Arch Oral Biol. 2001: 46; 412-23. Bardow A, Nyvad B, Nauntofte B. Relationships between medication intake and complaints of dry mouth, salivary flow rate and composition, and the rate of tooth demineralization in situ. Arch Oral Biol. 2001: 46; 412-23. © Lisa S Jacob, DDS, MS 2009

16. Time lapsed since child’s last cavity <12 months: High risk 12-24 months: Moderate risk >24 months: Low risk http://www.ntlf.com/images/calendar.jpg © Lisa S Jacob, DDS, MS 2009

17. Child wears braces or orthodontic/oral appliances Yes: High risk No: Low risk © Lisa S Jacob, DDS, MS 2009

18. Child’s immediate family has decay Yes: High risk  No: Low risk  Yes: High risk  No: Low risk  The earlier the child is infected… the higher the risk of caries the higher the risk of caries Vertical transmission Mother to child Vertical transmission ↓ Mother to child Horizontal transmission Sibling to sibling Horizontal transmission ↔ Sibling to sibling © Lisa S Jacob, DDS, MS 2009

19. Daily intakes Between-Meals and cavity producing foods Mealtimes: Low risk 1-2 snacks: Moderate risk >3 snacks: High risk Consumption of juice, carbonated beverages or sports drinks Use of bottle/sippy cup containing liquid other than water Use of sweetened medications © Lisa S Jacob, DDS, MS 2009

20. Child’s exposure to fluoride High Risk Does not use fluoridated toothpaste Does not use fluoridated toothpaste Drinking water is not fluoridated Drinking water is not fluoridated Does not take fluoride supplements Does not take fluoride supplements Moderate Risk Uses fluoridated toothpaste Uses fluoridated toothpaste Usually does not drink fluoridated water Usually does not drink fluoridated water Does not take fluoride supplements Does not take fluoride supplements Low Risk Uses fluoridated toothpaste Uses fluoridated toothpaste Drinks fluoridated water Drinks fluoridated water Takes fluoride supplements Takes fluoride supplements © Lisa S Jacob, DDS, MS 2009

21. Times per day that the child’s teeth/gums are brushed <1: High risk <1: High risk 1: Moderate risk 1: Moderate risk 2-3: Low risk 2-3: Low risk http://www.eslkidstuff.com/images/toothbrush. gif © Lisa S Jacob, DDS, MS 2009

22. Clinical Evaluation Clinical Evaluation © Lisa S Jacob, DDS, MS 2009

23. Visible Plaque Present: High risk Absent: Low risk http://www.scharfphoto.com/fine_art_prints/archives/199901-024-Dental-Plaque.jpg http://www.scharfphoto.com/fine_art_prints/archives/199901-024-Dental-Plaque.jpg © Lisa S Jacob, DDS, MS 2009

24. Gingivitis Present: High risk Absent: Low risk © Lisa S Jacob, DDS, MS 2009

25. Areas of enamel demineralization >1: High risk 1: Moderate risk None: Low risk http://www.uiowa.edu/~c090247/images/varnish/demineralized.jpg http://www.uiowa.edu/~c090247/images/varnish/demineralized.jpg © Lisa S Jacob, DDS, MS 2009

26. Enamel Defects Deep pits/fissures Present: High risk Absent: Low risk http://www.ojrd.com/content/figures/1750-1172-2- 17-1.jpg http://www.ojrd.com/content/figures/1750-1172-2- 17-1.jpg © Lisa S Jacob, DDS, MS 2009

27. Tooth anatomy and hypoplastic defects Developmental pits and deep pits have been shown to predispose a child to develop dental caries © Lisa S Jacob, DDS, MS 2009

28. Radiographic Enamel Caries Present: High risk Absent: Low risk http://www.ndeb.ca/en/accredited/images/SNAG-0202.jpg http://www.ndeb.ca/en/accredited/images/SNAG-0202.jpg © Lisa S Jacob, DDS, MS 2009

29. Levels of mutans streptococci or Lactobacilli High: High risk Moderate: Moderate risk Low: Low risk © Lisa S Jacob, DDS, MS 2009

30. Dental Record Document Caries Risk ▲ High ► Moderate ► Moderate ▼ Low © Lisa S Jacob, DDS, MS 2009

32. Topical Fluoride Varnish D1206 Topical Fluoride Varnish D1206 * Therapeutic application for moderate to high caries risk patients * Goal is to eliminate or control a disease * Prevent and re-mineralize early caries © Lisa S Jacob, DDS, MS 2009

33. Fluoride Varnish Advantages High dose with minimal volume Minimal swallowing Contact on teeth for hours Reduced caries Low plasma fluoride levels Tolerated by children Unit dose Fast © Lisa S Jacob, DDS, MS 2009

34. Fluoride Varnish 5% NAF Disadvantages Fuzzy, sticky and uneven Appearance on tooth 4-6 hours you can’t brush Soft food for one day © Lisa S Jacob, DDS, MS 2009

35. Topical Fluoride  Inhibits demineralization  Enhances re-mineralization  Inhibits plaque bacteria © Lisa S Jacob, DDS, MS 2009

36. Topical application of fluoride D1203 (Child) FoamsGels Most effective if placed in mouth for four minutes Most effective if placed in mouth for four minutes © Lisa S Jacob, DDS, MS 2009

37. Fluoride testing Fluori-check (Omnii Oral) © Lisa S Jacob, DDS, MS 2009

39. Fluoride Products © Lisa S Jacob, DDS, MS 2009

40. Oral Hygiene Instructions D1330 ToothbrushingFlossing © Lisa S Jacob, DDS, MS 2009

41. Toothbrushes Electric toothbrush Spin Brush © Lisa S Jacob, DDS, MS 2009

42. Surround Toothbrush _ 3 rows of bristles _ Compact head _ Helps protect the oral environment if the person moves unexpectedly during brushing © Lisa S Jacob, DDS, MS 2009

43. Flossers

44. Nutritional counseling for control of dental disease D1310 * Frequency of intake is more important than overall quantity * “Grazing” between meals should be discouraged * Avoid frequent consumption of sodas * Sweet intake should be limited-mealtime © Lisa S Jacob, DDS, MS 2009

45. Bacterial Cultures Identify the presence of cariogenic bacterial infections

46. Caries Susceptibility Test D0425 If mother has had active dental decay in the past 12 months, dentist may perform a bacterial culture on the mother If primary caregiver’s bacteria count is significant, the dentist will develop prevention strategy Minimizes the risk of mom transmitting the infection to the child © Lisa S Jacob, DDS, MS 2009

47. Recommendations for caregiver √ Antibacterial rinse √ Chew xylitol gum or mints each day Studies show that chewing xylitol gum 4 times a day helps reduce the transmission of cariogenic bacteria from caregivers to infants © Lisa S Jacob, DDS, MS 2009

48. Dental anticipatory Guidance * Age appropriate information/education for parents * Multi-topic overview of oral health environmental influences * Directed at increasing the parents understanding of the importance of good health © Lisa S Jacob, DDS, MS 2009

49. Dental anticipatory Guidance * Discuss oral health and home care * Development of Mouth and Teeth * Oral Habits * Diet, Nutrition and Food Choices * Fluoride Needs * Injury Prevention * Antimicrobials © Lisa S Jacob, DDS, MS 2009

50. Birth -1 year old √ Clean baby’s mouth/brush teeth √ Parents need to maintain their own oral health √ Do not share utensils and cups √ Discuss primary tooth eruption patterns √ Discuss teething and ways to sooth sore gums © Lisa S Jacob, DDS, MS 2009

51. Birth-1 year old √ Review pacifier use √ Do not put baby to bed with bottle √ Encourage use of cup by year one √ Fluoride needs √ Child proof the home √ Car seat usage √ Discuss use of medications with sweeteners © Lisa S Jacob, DDS, MS 2009

52. 1-3 years old ☺ Offer healthy food, snacks, drinks ☺ Clean baby’s teeth ☺ Use fluoridated toothpaste (smear) ☺ Continue regular dental visits ☺ Discuss importance of baby teeth with parents ☺ Begin weaning of non-nutritive sucking habits by age 2 © Lisa S Jacob, DDS, MS 2009

53. 1-3 years old Continue ☺ Healthy nutritional choices ☺ Frequency of exposures  Do not use sippy cup like a bottle  No running with objects in mouth  Helmet use with toddlers riding bikes © Lisa S Jacob, DDS, MS 2009

54. 3-5 years old * Pea-sized amount of fluoridated toothpaste * Discuss permanent tooth eruption patterns * Importance of teeth * Discuss consequences of digit sucking or prolonged non nutritive sucking * Should be using a regular cup © Lisa S Jacob, DDS, MS 2009

55. Behavior Guidance * “a clinical art form and skill built on a foundation of science” * Continuum of interaction involving the dentist, dental team, the parent, and the patient © Lisa S Jacob, DDS, MS 2009

56. Goals √ Establish communication √ Alleviate fear and anxiety √ Deliver quality dental care √ Build a trusting relationship between dentist and child √ Promote child’s positive attitude toward dental health © Lisa S Jacob, DDS, MS 2009

57. Dental Office Website __ Introduce parents to the practice Location __ FQHC dental within medical clinic Design Design __ Kid friendly © Lisa S Jacob, DDS, MS 2009

58. DENTAL TEAM BEHAVIOR Receptionist __ First contact with parent via phone __ Sets expectations __ First staff member the child meets Dental Assistant __ Language Dental Hygienist __ Establish rapport Dentist __ “White Coat Syndrome” © Lisa S Jacob, DDS, MS 2009

59. Recommend behavior guidance based on: * Health history * Special health needs * Dental Needs * Type of treatment required required * Consequences of no treatment * Emotional and intellectual development of patient * Parental preferences © Lisa S Jacob, DDS, MS 2009

60. BASIC BEHAVIOR GUIDANCE  © Lisa S Jacob, DDS, MS 2009

61. VOICE CONTROL Gain the patient’ attention Establish adult-child roles Controlled alteration of : Voice Volume Pace Tone © Lisa S Jacob, DDS, MS 2009

62. Non-verbal Communication Reinforcement and guidance of behavior through: Appropriate contact Posture Body Language Facial Expression Gain or maintain the patient’s attention © Lisa S Jacob, DDS, MS 2009

63. TELL-SHOW-DO Tailored verbal explanation of procedures Educate – importance of dental visit Familiarize patient with dental setting Demonstrate: It’s OK to Visual, Auditory,Touch,Taste, Smell Visual, Auditory,Touch,Taste, Smell © Lisa S Jacob, DDS, MS 2009

64. POSITIVE REINFORCEMENT Rewarding desired behavior ☺ Verbal praise ☺ Prizes ☺ Facial expression Gives appropriate feedback Strengthens recurrence of those behaviors © Lisa S Jacob, DDS, MS 2009

65. DISTRACTION Diverting the patient’s attention from what may be perceived as an unpleasant procedure ≈ Find out interests ≈ Give patient a short break © Lisa S Jacob, DDS, MS 2009

66. PARENTAL PRESENCE/ABSENCE __ Gain patient’s attention __ Improve compliance __ Depends on if the parent can help reduce the patient’s anxiety __ Parental attitudes have changed __ Legal reasons __ Do not use with parents who are unwilling or unable to extend effective support © Lisa S Jacob, DDS, MS 2009

67. MODELING Have a patient observe the positive behavior of another patient © Lisa S Jacob, DDS, MS 2009

68. HYPNOSIS Guided self-imagery that focuses in relaxation and analgesia * Helps decrease gagging * Helps overcome dental phobia © Lisa S Jacob, DDS, MS 2009

69. ADVANCE BEHAVIOR GUIDANCE → Protective Stabilization → Nitrous oxide → Conscious Sedation → General anesthesia © Lisa S Jacob, DDS, MS 2009

70. PROTECTIVE STABILIZATION * Any form of restriction of movement by a patient in the dental environment * Reduce or eliminate untoward patient movement * Protect patient, staff, dentist or parent from injury * Facilitate delivery of quality dental care © Lisa S Jacob, DDS, MS 2009

71. INDICATIONS Patient requires immediate diagnosis or limited treatment Patient requires immediate diagnosis or limited treatment Use with sedated patient that need to help reduce untoward movement Use with sedated patient that need to help reduce untoward movement © Lisa S Jacob, DDS, MS 2009

72. PHYSICAL RESTRAINS Head holds Hand guarding Used by dental assistant Therapeutic holds Third person © Lisa S Jacob, DDS, MS 2009

73. Dental Record for any use of Stabilization Informed consent IndicationType Duration of application Frequency of stabilization evaluation and safety adjustments Behavior evaluation/rating during stabilization © Lisa S Jacob, DDS, MS 2009

74. Precautions with protective stabilization √ Tightness and duration must be monitored √ Do not restrict breathing and circulation √ Must not use if patient experiences severe stress or hysteria © Lisa S Jacob, DDS, MS 2009

75. MOUTH PROPS McKesson Bite Block Molt © Lisa S Jacob, DDS, MS 2009

76. Mouth Rest Open Wide Mouth Rest- Disposable Reusable Can hold a saliva ejector in place © Lisa S Jacob, DDS, MS 2009

77. Positioning Devices ☺ Wheelchair head supports ☺ Bean Bags ☺ Rainbow Airway Positioner © Lisa S Jacob, DDS, MS 2009

78. Stay N Place Booster Chair © Lisa S Jacob, DDS, MS 2009

79. Rainbow Elbow and Knee Stabilizers Easy to apply and remove “Incremental Relaxation” teaching tool for patients to learn safe behavior © Lisa S Jacob, DDS, MS 2009

80. Pedi-Wrap

81. NITROUS OXIDE Safe and effective technique to Reduce anxiety Enhance effective communication Rapid onset of action Easily titrated and reversible Rapid recovery Helps with: analgesia, amnesia and gag reflex reduction © Lisa S Jacob, DDS, MS 2009

82. CONSCIOUS SEDATION √ Control anxiety √ Minimize psychological trauma √ Maximize potential of amnesia √ Control behavior movement © Lisa S Jacob, DDS, MS 2009

83. DENTAL RECORD * Informed consent * Instructions and information * Medical evaluation * Time based record monitoring patient HR, BP, RR, Oxygen saturation * Adverse events * Time and condition of patient at discharge © Lisa S Jacob, DDS, MS 2009

84. General Anesthesia * Controlled state of unconsciousness accompanied with a loss of protective reflexes * Provide safe, efficient and effective dental care * Eliminate anxiety * Reduce untoward movement * Aid in treatment of mentally, physically or medically compromised patient © Lisa S Jacob, DDS, MS 2009

85. Minimal Intervention * Modern medical approach to the management of oral disease * Early Diagnosis * Change environment * Repair © Lisa S Jacob, DDS, MS 2009

86. Early Detection Identify Assess any potential caries risk factors Recognition White spot lesions Gingivitis © Lisa S Jacob, DDS, MS 2009

87. Change Environment Prevent Minimize risk factors to prevent caries Rebalance oral environment Remineralize © Lisa S Jacob, DDS, MS 2009

88. RESTORE Restore tooth with bioactive materials Preserve tooth structure Repair http:// www.wpclipart.com/tools/hammer/hammer_1.png © Lisa S Jacob, DDS, MS 2009

89. Dental Restorative Material Glass Ionomer Glass Ionomer Composite Composite Amalgam Amalgam Resin Crown Resin Crown Stainless steel crown Stainless steel crown © Lisa S Jacob, DDS, MS 2009

90. Glass Ionomer Restorations Fluoride release Fluoride release Primary and permanent teeth Primary and permanent teeth Cement stainless steel crowns Cement stainless steel crowns Orthodontic appliances Orthodontic appliances Transitional restorations for caries control Transitional restorations for caries control Tooth isolation Tooth isolation High caries risk High caries risk Base Base © Lisa S Jacob, DDS, MS 2009

91. Resin-based composite Excellent restoration in primary and permanent dentition in low caries risk patient May not be ideal for patient at high risk for dental decay May not be ideal for patient at high risk for dental decay Donly KJ, Garcia-Godoy F. The use of resin-based composite in children. Pediatric Dentistry. 2002: 24; 480-8. Donly KJ, Garcia-Godoy F. The use of resin-based composite in children. Pediatric Dentistry. 2002: 24; 480-8. © Lisa S Jacob, DDS, MS 2009

92. Frequency of Radiographs Depends on caries risk of patient ADA/FDA Guidelines © Lisa S Jacob, DDS, MS 2009

93. Low Caries Risk Primary and Mixed Dentition Bitewings every 12-24 months Adolescent with permanent dentition Bitewings every 18-36 months Adult Dentate or partially edentulous Bitewings every 24-36 months © Lisa S Jacob, DDS, MS 2009

94. High Caries Risk Child and adolescent with permanent dentitions Bitewings should be taken every 6-12 months Adult dentate or Partially Edentulous Bitewings every 6-18 months © Lisa S Jacob, DDS, MS 2009

95. Frequency of Recall Exam and Prophys Low Risk: Every year Moderate Risk: Every 6 months High risk: Every 3 months © Lisa S Jacob, DDS, MS 2009

96. Frequency of Prophylaxis Depends on caries risk of patient at discretion of practitioner. © Lisa S Jacob, DDS, MS 2009

97. Low Caries Risk Goal is to MAINTAIN Recall exam every year Radiographs Every 12-18 months in primary teeth Every 2 years in permanent teeth Continue good diet and oral hygiene Daily use of fluoridated toothpaste © Lisa S Jacob, DDS, MS 2009

98. Moderate Caries Risk _ Goal is to REPAIR _ Recall every six months _ Radiographs every 18-24 months _ Fluoride varnish every 6 months _ Daily use of xylitol or fluoride rinse _ Change Behavior by decreasing snacking © Lisa S Jacob, DDS, MS 2009

99. High Caries risk Goal is to REPAIR and RESTORE Recall every three months Radiographs every 6-12 months Glass ionomer as an interim material Fluoride varnish every 3 months Chew 5 pieces of xylitol gum every day © Lisa S Jacob, DDS, MS 2009

100. High Caries Risk * Counsel on diet * Review oral hygiene instructions © Lisa S Jacob, DDS, MS 2009

101. Take Home Messages for Parents Cavities are preventable Caries is an infectious disease Transmitted from parents/caregivers © Lisa S Jacob, DDS, MS 2009

102. Suggestions for Practitioners √ Be flexible √ Be flexible √ Be consistent √ Be Compassionate √ PRAISE, PRAISE, PRAISE © Lisa S Jacob, DDS, MS 2009

103. Q&A Session © Lisa S Jacob, DDS, MS 2009