Management of Caries
The adolescent should receive maximum fluoride benefit dependent on risk assessment (see the National Guideline Clearinghouse [NGC] summary of the American Academy of Pediatric Dentistry [AAPD] Guideline on Caries-Risk Assessment and Management for Infants, Children and Adolescents.
- Brushing teeth twice a day with a fluoridated dentifrice is recommended to provide continuing topical benefits (see the NGC summary of the AAPD Guideline on Fluoride Therapy; Burt, 1998)
- Professionally applied fluoride treatments should be based on the individual patient's caries-risk assessment, as determined by the patient's dental provider (see the NGC summary of the AAPD Guideline on Fluoride Therapy).
- Home-applied prescription strength topical fluoride products (e.g., 0.4% stannous fluoride gel, 0.5% fluoride gel or paste, 0.2% sodium fluoride [NaF] rinse) may be used when indicated by an individual's caries pattern or caries risk status (see the NGC summary of the AAPD Guideline on Fluoride Therapy).
- Systemic fluoride intake via optimal fluoridation of drinking water or professionally prescribed supplements is recommended to 16 years of age. Supplements should be given only after all other sources of fluoride have been evaluated (see the NGC summary of the AAPD Guideline on Fluoride Therapy).
- The criteria for determination of need and the methods of delivery should be those currently recommended by the American Dental Association and the AAPD (see the NGC summary of the AAPD Guideline on Fluoride Therapy ).
- Adolescents should be educated and motivated to maintain personal oral hygiene through daily plaque removal, including flossing, with the frequency and pattern based on the individual's disease pattern and oral hygiene needs (Macgregor, Balding, & Regis, 1996; Dean & Hughes, 2011).
- Professional removal of plaque and calculus is recommended highly for the adolescent, with the frequency of such intervention based on the individual's assessed risk for caries/periodontal disease, as determined by the patient's dental provider (see the NGC summary of the AAPD Guideline on Periodicity of Examinations, Preventive Dental Services, Anticipatory Guidance/Counseling, and Oral Treatment for Infants, Children, and Adolescents; Dean & Hughes, 2011).
Diet analysis, along with professionally determined recommendations for maximal general and dental health, should be part of an adolescent's dental health management (AAPD, "Policy on dietary," 2009).
A diet analysis and management should consider:
- Dental disease patterns
- Overall nutrient and energy needs
- Psychosocial aspects of adolescent nutrition
- Dietary carbohydrate intake and frequency
- Intake and frequency of acid-containing beverages
- Wellness considerations
Adolescents at risk for caries should have sealants placed. An individual's caries risk may change over time; periodic reassessment for sealant need is indicated throughout adolescence (see the NGC summary of the AAPD Guideline on Pediatric Restorative Dentistry).
Professional Preventive Care
- Timing of periodic oral examinations should take into consideration the individual's needs and risk indicators to determine the most cost-effective, disease-preventive benefit to the adolescent (see the NGC summary of the AAPD Guideline on Caries-Risk Assessment and Management for Infants, Children and Adolescents).
- Initial and periodic radiographic evaluation should be a part of a clinical evaluation. The type, number, and frequency of radiographs should be determined only after an oral examination and history taking. Previously exposed radiographs should be available, whenever possible, for comparison. Currently accepted guidelines for radiographic exposures (i.e., appropriate films based upon medical history, caries risk, history of periodontal disease, and growth and development assessments) should be followed (AAPD, "Guideline on prescribing dental radiographs," 2009).
Each adolescent patient and restoration must be evaluated on an individual basis. Preservation of noncarious tooth structure is desirable. Referral should be made when treatment needs are beyond the treating dentist's scope of practice (see the NGC summary of the AAPD Guideline on Pediatric Restorative Dentistry).
Acute intraoral infection involving the periodontium and oral mucosa requires immediate treatment. Therapeutic management should be based on currently accepted techniques of periodontal therapy (Litonjua, 1996; Greenwell, 2001). Referral should be made when the treatment needs are beyond the treating dentist's scope of practice.
The adolescent will benefit from an individualized preventive dental health program, which includes the following items aimed specifically at periodontal health:
- Patient education emphasizing the etiology, characteristics, and prevention of periodontal diseases, as well as self-hygiene skills (Wilson & Kornman, 2003; Modeer & Wondimu, 2000; Grossi et al., 1994).
- A personal, age-appropriate oral hygiene program including plaque removal, oral health self-assessment, and diet. Sulcular brushing and flossing should be included in plaque removal, and frequent follow-up to determine adequacy of plaque removal and improvement of gingival health should be considered (Wilson & Kornman, 2003; Modeer & Wondimu, 2000; Grossi et al., 1994; Grossi et al., 1995; Litonjua, 1996).
- Regular professional intervention, the frequency of which should be based on individual needs and should include evaluation of personal oral hygiene success, periodontal status, and potential complicating factors such as medical conditions, malocclusion, or handicapping conditions. Periodontal probing, periodontal charting, and radiographic periodontal diagnosis should be a consideration when caring for the adolescent. The extent and nature of the periodontal evaluation should be determined professionally on an individual basis. Those patients with progressive periodontal disease should be referred when the treatment needs are beyond the treating dentist's scope of practice (Wilson & Kornman, 2003; Modeer & Wondimu, 2000; Grossi et al., 1994; Litonjua, 1996).
- Appropriate evaluation for procedures to facilitate orthodontic treatment including, but not limited to, tooth exposure, frenectomy, fiberotomy, gingival augmentation, and implant placement (Greenwell, 2001).
Malposition of teeth, malrelationship of teeth to jaws, tooth/jaw size discrepancy, skeletal malrelationship, or craniofacial malformations or disfigurement that presents functional, esthetic, physiologic, or emotional problems to the adolescent should be referred for evaluation when the treatment needs are beyond the treating dentist's scope of practice. Treatment of malocclusion by a dentist should be based on professional diagnosis, available treatment options, patient motivation and readiness, and other factors to maximize progress (Richardson & Russell, 2001).
Evaluation of third molars, including radiographic diagnostic aids, should be an integral part of the dental examination of the adolescent (AAPD, "Guideline on prescribing dental radiographs," 2009). For diagnostic and extraction criteria, refer to the AAPD Guideline on Pediatric Oral Surgery (see the NCG summary of this guideline). Referral should be made if treatment is beyond the treating dentist's scope of practice.
Temporomandibular Joint (TMJ) Problems
Evaluation of the temporomandibular joint and related structures should be a part of the examination of the adolescent. Referral should be made when the diagnostic and/or treatment needs are beyond the treating dentist's scope of practice (National Institutes of Health, 1996; Skeppar & Nilner, 1993).
Congenitally Missing Teeth
Evaluation of congenitally missing permanent teeth should include both immediate and long-term management. Referral should be made when the treatment needs are beyond the treating dentist's scope of practice. A team approach may be indicated (see the NGC summary of the AAPD Guideline on Management of the Developing Dentition and Occlusion).
The dentist should be proactive in diagnosing and treating ectopic eruption and impacted teeth in the young adolescent. Early diagnosis, including appropriate radiographic examination (AAPD, "Guideline on prescribing dental radiographs," 2009), is important. Referral should be made when the treatment needs are beyond the treating dentist's scope of practice (see the NGC summary of the AAPD Guideline on Management of the Developing Dentition and Occlusion).
Dentists should introduce a comprehensive trauma prevention program to help reduce the incidence of traumatic injury to the adolescent dentition. This prevention plan should consider assessment of the patient's sport or activity, including level and frequency of activity (Ranalli, 2002). Once this information is acquired, recommendation and fabrication of an age-appropriate, sport-specific, and properly fitted mouthguard/faceguard can be initiated (Ranalli, 2002). Players must be warned about altering the protective equipment that will disrupt the fit of the appliance. In addition, players and parents must be informed that injury may occur, even with properly fitted protective equipment (Ranalli, 2002).
Additional Considerations in Oral/Dental Management of the Adolescent
Discolored or Stained Teeth
For the adolescent patient, judicious use of bleaching can be considered part of a comprehensive, sequenced treatment plan that takes into consideration the patient's dental developmental stage, oral hygiene, and caries status. A dentist should monitor the bleaching process, ensuring the least invasive, most effective treatment method. Dental professionals also should consider possible side effects when contemplating dental bleaching for adolescent patients (Li, 1998; AAPD, "Policy on use of dental bleaching," 2009).
Education of the adolescent patient on the oral and systemic consequences of tobacco use should be part of each patient's oral health education. For those adolescent patients who use tobacco products, the practitioner should provide or refer the patient to appropriate educational and counseling services (American Dental Association, 1993; American Cancer Society, National Cancer Institute, & National Institutes of Health, 1998; AAPD, "Policy on tobacco use," 2010). When associated pathology is present, referral should be made when the treatment needs are beyond the treating dentist's scope of practice.
Positive Youth Development (PYD)
Integrating PYD into clinical practice can be attained through continuing education on adolescent development issues, as well as partnerships with community-based organizations and schools. The dentist can be a part of the myriad of adolescent support and services (Larson, 2000).
Psychosocial and Other Considerations
- An adolescent's oral health care should be provided by a dentist who has appropriate training in managing the patient's specific needs. Referral should be made when the treatment needs are beyond the treating dentist's scope of practice. This may include both dental and nondental problems (Larson, 2000).
- Attention should be given to the particular psychosocial aspects of adolescent dental care. Other issues such as consent, confidentiality, and compliance should be addressed in the care of these patients (see the NGC summary of the AAPD Guideline on Informed Consent; AAPD, "Guideline on record keeping," 2009).
- A complete oral health care program for the adolescent requires an educational component that addresses the particular concerns and needs of the adolescent patient and focuses on:
- Specific behaviorally and physiologically induced oral manifestations in this age group (Dean & Hughes, 2011)
- Shared responsibility for care and health by the adolescent and provider (Dean & Hughes, 2011)
- Consequences of adolescent behavior on oral health (Romito & McDonald, 2011; Macgregor & Balding, 1991)
Transitioning to Adult Care
At a time agreed upon by the patient, parent, and pediatric dentist, the patient should be transitioned to a dentist knowledgeable and comfortable with managing that patient's specific oral care needs. For the special health care needs patient, in cases where it is not possible or desired to transition to another practitioner, the dental home can remain with the pediatric dentist and appropriate referrals for specialized dental care should be recommended when needed (see the NGC summary of the AAPD Guideline on Management of Dental Patients with Special Health Care Needs).