Management of Caries
Primary Prevention
Fluoride
The adolescent should receive maximum fluoride benefit:
- Systemic fluoride intake via optimal fluoridation of drinking water or professionally prescribed supplements is recommended to 16 years of age or the eruption of the second permanent molars, whichever comes first
- Fluoridated dentifrice is recommended to provide continuing topical benefits through adolescence
- Professionally applied fluoride treatments should be based on the individual patient's caries-risk assessment, as determined by the patient's dental provider
- Topical fluoride supplementation via home-applied compounds should be a professional recommendation when indicated by an individual's caries pattern or caries-risk status
- The criteria for determination of need and the methods of delivery should be those currently recommended by the American Dental Association and the American Academy of Pediatric Dentistry (American Academy of Pediatric Dentistry [AAPD], "Clinical guideline on fluoride therapy," 2004)
Oral Hygiene
- 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
- 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 (AAPD, "Clinical guideline on periodicity," 2004)
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. 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
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 (AAPD, "Clinical guideline on pediatric restorative dentistry," 2004).
Secondary Prevention
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
- 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, "Clinical guideline on prescribing dental radiographs," 2005)
Restorative Dentistry
Each adolescent patient and restoration must be evaluated on an individual basis. Preservation of non-carious tooth structure is desirable. Referral to an appropriately trained and/or experienced dentist should be considered when treatment needs are beyond the treating dentist's ability or interest.
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. Traumatic injuries to the teeth and periodontium always require dental evaluation and treatment. Referral to an appropriately trained and/or experienced dentist should be considered when the treatment needs are beyond the treating dentist's ability or interest.
Chronic Conditions
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
- 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
- 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 to an appropriately trained and/or experienced dentist for evaluation and treatment
- 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
Any malposition of teeth, malrelationship of teeth to jaws, tooth/jaw size discrepancy, bimaxillary malrelationship, or craniofacial malformations or disfigurement that presents functional, esthetic, physiologic, or emotional problems to the adolescent should be evaluated by the appropriately trained dentist or professional team. Treatment of malocclusion by an appropriately trained and/or experienced dentist should be based on professional diagnosis, available treatment options, patient motivation and readiness, and other factors to maximize progress.
Third Molars
Evaluation of third molars, including radiographic diagnostic aids, should be an integral part of the dental examination of the adolescent (AAPD, "Clinical guideline on prescribing dental radiographs," 2005). For diagnostic and extraction criteria, refer to the AAPD Clinical Guideline on Pediatric Oral Surgery (AAPD, "Clinical guideline on pediatric oral surgery," 2005). Treatment of third molars that are potential or active problems should be performed by an appropriately trained and/or experienced dentist.
Temporomandibular Joint Problems
Evaluation of the temporomandibular joint and related structures should be a part of the examination of the adolescent. Abnormalities should be managed by an appropriately trained and/or experienced dentist following accepted clinical procedures (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. Management should be by an appropriately trained and/or experienced dentist, and a team approach may be indicated (AAPD, "Clinical guideline on management of the developing dentition," 2005).
Ectopic Eruption
The dentist should be proactive in diagnosing and treating ectopic eruption in the young adolescent. Early diagnosis, including appropriate radiographic examination (AAPD, Clinical guideline on prescribing dental radiographs, 2005) of ectopic eruption is important. An appropriately trained and/or experienced dentist should manage treatment and a team approach may be necessary (AAPD, Clinical guideline on management of the developing dentition, 2005).
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 as a 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 dental bleaching," 2004).
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, NIH, 1998; AAPD, "Policy on Tobacco Use," 2005). When associated pathology is present, treatment should be managed by an appropriately trained and/or experienced health care provider.
Positive Youth Development (PYD)
PYD should be recognized as containing a number of key elements that are relevant to care of this age patient:
- Providing youth with safe and supportive environments
- Fostering relationships between young people and caring adults who can mentor and guide them
- Promoting healthy lifestyles and teaching positive patterns of social interaction
- Providing a safety net in times of need (Department of Health and Human Services, 2002)
Psychosocial and Other Considerations
- Oral health care of the adolescent should be provided by a dentist who has appropriate training in managing the specific needs of this patient. The primary care dentist should consider referral to a specialist for treatment of particular problems outside his or her expertise. This may include both dental and non-dental problems.
- Attention should be given to the particular psychosocial aspects of adolescent dental care. Issues of consent, confidentiality, compliance, and others should be addressed in the care of these patients (AAPD, "Clinical guideline on record keeping," 2004; AAPD, "Clinical guideline on informed consent," 2005)
- 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
- Shared responsibility for care and health by the adolescent and provider
- Consequences of adolescent behavior on oral health
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 patient with special health care needs (SHCN), 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 (AAPD, "Clinical guideline on management of persons with special health care needs," 2004).
