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Guideline Summary
Guideline Title
Guideline on adolescent oral health care.
Bibliographic Source(s)
American Academy of Pediatric Dentistry (AAPD). Guideline on adolescent oral health care. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2010. 8 p. [83 references]
Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American Academy of Pediatric Dentistry. Clinical guideline on adolescent oral health care. Chicago (IL): American Academy of Pediatric Dentistry; 2005. 10 p.

Scope

Disease/Condition(s)

Adolescent oral health conditions, including:

  • Dental caries and plaque
  • Periodontal diseases (e.g., gingivitis, periodontitis)
  • Malocclusion
  • Third molar problems
  • Temporomandibular joint problems
  • Congenitally missing teeth
  • Ectopic eruption
  • Traumatic injuries to the teeth
  • Discolored or stained teeth
  • Oral and dental disease due to tobacco use
  • Psychosocial effects on dental health
Guideline Category
Counseling
Evaluation
Management
Prevention
Risk Assessment
Treatment
Clinical Specialty
Dentistry
Pediatrics
Intended Users
Allied Health Personnel
Dentists
Nurses
Physicians
Guideline Objective(s)

To address the unique needs and propose general recommendations for the management of oral health care in the adolescent patient

Target Population

Adolescents

Interventions and Practices Considered

Evaluation/Prevention

  1. Fluoridation
    • Fluoridated dentifrice
    • Professionally applied fluoride treatments
    • Topical fluoride products
    • Oral fluoridation
  2. Oral hygiene care
    • Daily plaque removal including flossing
    • Professional plaque and calculus removal
  3. Diet analysis and management
  4. Sealant placement
  5. Periodic oral examination
  6. Initial and periodic radiographic evaluation
  7. Traumatic injury prevention program
  8. Patient education

Treatment/Management

  1. Restorative dentistry
  2. Intraoral infection management
  3. Individualized preventive dental health program including patient education, oral hygiene program, professional intervention, and appropriate evaluation
  4. Malocclusion treatment
  5. Third molar treatment
  6. Evaluation and management of temporomandibular joint problems
  7. Evaluation and management of congenitally missing teeth
  8. Diagnosis and treatment of ectopic eruptions
  9. Bleaching of stained or discolored teeth
  10. Education on consequences of tobacco use
  11. Integration of positive youth development
  12. Attention to psychosocial aspects of adolescent care
  13. Transitioning to adult care
  14. Referral, as needed
Major Outcomes Considered
  • Rate of caries development
  • Incidence of periodontal disease
  • Incidence of oral problems associated with adolescent behavior

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

The guideline is an update of the previous document, revised in 2005. The update includes an electronic search using the following parameters: Terms: "adolescent" combined with "dental," "gingivitis," "oral piercing," "sealants," "oral health," "caries," "tobacco use," "dental trauma," "orofacial trauma," "periodontal," "dental esthetics," "smokeless tobacco," "nutrition," and "diet"; Fields: all fields; Limits: within the last 10 years; humans; English; clinical trials.

Number of Source Documents

Eighty-three electronic and hand searched articles met the defined criteria and were included.

Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus (Committee)
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The oral health policies and clinical guidelines of the American Academy of Pediatric Dentistry (AAPD) are developed under the direction of the Board of Trustees, utilizing the resources and expertise of its membership operating through the Council on Clinical Affairs (CCA).

Proposals to develop or modify policies and guidelines may originate from 4 sources:

  1. The officers or trustees acting at any meeting of the Board of Trustees
  2. A council, committee, or task force in its report to the Board of Trustees
  3. Any member of the AAPD acting through the Reference Committee hearing of the General Assembly at the Annual Session
  4. Officers, trustees, council and committee chairs, or other participants at the AAPD's Annual Strategic Planning Session

Regardless of the source, proposals are considered carefully, and those deemed sufficiently meritorious by a majority vote of the Board of Trustees are referred to the CCA for development or review/revision.

Once a charge (directive from the Board of Trustees) for development or review/revision of an oral health policy or clinical guideline is sent to the CCA, it is assigned to 1 or more members of the CCA for completion. CCA members are instructed to follow the specified format for a policy or guideline. All oral health policies and clinical guidelines are based on 2 sources of evidence: (1) the scientific literature; and (2) experts in the field. Members may call upon any expert as a consultant to the council to provide expert opinion. The Council on Scientific Affairs provides input as to the scientific validity of a policy or guideline.

The CCA meets on an interim basis (midwinter) to discuss proposed oral health policies and clinical guidelines. Each new or reviewed/revised policy and guideline is reviewed, discussed, and confirmed by the entire council.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation

Once developed by the Council on Clinical Affairs (CCA), the proposed policy or guideline is submitted for the consideration of the Board of Trustees. While the board may request revision, in which case it is returned to the council for modification, once accepted by majority vote of the board, it is referred for Reference Committee hearing at the upcoming Annual Session. At the Reference Committee hearing, the membership may provide comment or suggestion for alteration of the document before presentation to the General Assembly. The final document then is presented for ratification by a majority vote of the membership present and voting at the General Assembly. If accepted by the General Assembly, either as proposed or as amended by that body, the document then becomes the official American Academy of Pediatric Dentistry (AAPD) oral health policy or clinical guideline for publication in the AAPD's Reference Manual and on the AAPD's Web site.

Recommendations

Major Recommendations

Management of Caries

Primary Prevention

Fluoride

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.

  1. Brushing teeth twice a day with a fluoridated dentifrice is recommended to provide continuing topical benefits (Burt, 1998)
  2. Professionally applied fluoride treatments should be based on the individual patient's caries-risk assessment, as determined by the patient's dental provider.
  3. 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.
  4. 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.
  5. The criteria for determination of need and the methods of delivery should be those currently recommended by the American Dental Association and the AAPD.

Oral Hygiene

  1. 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).
  2. 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 Management

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:

  1. Dental disease patterns
  2. Overall nutrient and energy needs
  3. Psychosocial aspects of adolescent nutrition
  4. Dietary carbohydrate intake and frequency
  5. Intake and frequency of acid-containing beverages
  6. Wellness considerations

Sealants

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.

Secondary Prevention

Professional Preventive Care

  1. 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).
  2. 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).

Restorative Dentistry

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.

Periodontal Diseases

Acute Conditions

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.

Chronic Conditions

The adolescent will benefit from an individualized preventive dental health program, which includes the following items aimed specifically at periodontal health:

  1. 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).
  2. 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).
  3. 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).
  4. Appropriate evaluation for procedures to facilitate orthodontic treatment including, but not limited to, tooth exposure, frenectomy, fiberotomy, gingival augmentation, and implant placement (Greenwell, 2001).

Occlusal Considerations

Malocclusion

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).

Third Molars

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).

Ectopic Eruption

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).

Traumatic Injuries

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).

Tobacco Use

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

  1. 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).
  2. 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).
  3. 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:
    1. Specific behaviorally and physiologically induced oral manifestations in this age group (Dean & Hughes, 2011)
    2. Shared responsibility for care and health by the adolescent and provider (Dean & Hughes, 2011)
    3. 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.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

References Supporting the Recommendations
Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is not specifically stated for each recommendation.

When data did not appear sufficient or were inconclusive, recommendations were based upon expert and/or consensus opinion by experienced researchers and clinicians.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate oral health care and decrease in the incidence of periodontal disease in adolescent patients

Potential Harms

Not stated

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Chart Documentation/Checklists/Forms
Patient Resources
Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
American Academy of Pediatric Dentistry (AAPD). Guideline on adolescent oral health care. Chicago (IL): American Academy of Pediatric Dentistry (AAPD); 2010. 8 p. [83 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
1986 (updated 2010)
Guideline Developer(s)
American Academy of Pediatric Dentistry - Professional Association
Source(s) of Funding

American Academy of Pediatric Dentistry

Guideline Committee

Clinical Affairs Committee

Composition of Group That Authored the Guideline

Not stated

Financial Disclosures/Conflicts of Interest

Council members and consultants derive no financial compensation from the American Academy of Pediatric Dentistry for their participation and are asked to disclose potential conflicts of interest.

Guideline Status

This is the current release of the guideline.

This guideline updates a previous version: American Academy of Pediatric Dentistry. Clinical guideline on adolescent oral health care. Chicago (IL): American Academy of Pediatric Dentistry; 2005. 10 p.

Guideline Availability

Electronic copies: Available from the American Academy of Pediatric Dentistry Web site External Web Site Policy.

Print copies: Available from the American Academy of Pediatric Dentistry, 211 East Chicago Avenue, Suite 700, Chicago, Illinois 60611.

Availability of Companion Documents

The following is available:

  • Overview. American Academy of Pediatric Dentistry 2010-11 definitions, oral health policies, and clinical guidelines. Chicago (IL): American Academy of Pediatric Dentistry; 2010. 2 p. Electronic copies: Available in Portable Document Format (PDF) from the American Academy of Pediatric Dentistry Web site External Web Site Policy.

The following are also available from the American Academy of Pediatric Dentistry (AAPD) Web site:

Patient Resources

The following is available:

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI on August 18, 2005. This NGC summary was updated by ECRI Institute on December 29, 2010. The updated information was verified by the guideline developer on May 9, 2011.

Copyright Statement

This summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouseâ„¢ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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