A New Approach to Adolescent Oral Health
In my 20 years of general dental practice, I have always found adolescents to be my most intriguing and enjoyable patients. These patients inspire me, question the obvious, and take nothing for granted. They want clear communication from adults - plain talk and the truth.
Even though many of my adolescent patients had increased caries and gingivitis, it was not until my own daughter became a teenager that I began to research and become aware of increased risk factors for adolescent oral health. I treated my daughter and her friends, who all had very good oral health until early adolescence, when they had a sudden increase in caries and gingivitis, despite proper home care. Why was there increased caries activity and puberty gingivitis? Why was our prevention program not working? Why were home care tools, techniques, and products not producing effective results?
According to the American Academy of Periodontology, both normal and abnormal changes in pubertal hormone levels can modify the gingival inflammatory response to dental plaque.1 This can account for the changes that I saw among the adolescents in my practice. Hormonally induced changes in the inflammatory response include increased endothelial damage, increased vascular permeability, altered recruitment of leukocytes to inflamed tissue, altered formation of granulation tissue, and changes in the composition of the subgingival flora.2
With the morphologic changes of growth and development, including eruption gingivitis with new permanent teeth, and the changing anatomy of the gingiva, the junctional epithelium of the permanent tooth gingiva appears thinner than that of a primary tooth. This increases the permeability of the epithelium to bacterial toxins.3 There is additional evidence that the composition of the plaque changes during puberty to include an increase in gram-negative bacteria.4
A cascade of systemic physiologic events among teenagers could increase their likelihood for oral diseases, along with other localized risk factors, such as supra- and sub-gingival plaque and calculus, sub-gingival restoration margins, malocclusion, orthodontic appliances, and mouth-breathing. With the nearly constant availability of sugars and simple carbohydrates to feed plaque, it is not surprising that adolescent caries and gingivitis are so common, even among the healthiest teenagers.
Adolescents may not access routine medical and dental care. As women dentists, we are more likely to see adolescents on a routine basis than their primary physicians, so it is a good idea for us to be aware of overall systemic and oral health issues. This was affirmed by the Surgeon General’s report, “Oral Health in America,” which stated that adolescents through young adults most underutilize health care and have the greatest risk of inadequate dental care.5
Our new approach to adolescent oral health should take into account the context in which our adolescents live. The hormonal changes alone cause enough difficulties for managing oral health, as adolescents must successfully navigate the processes of development.
As if this isn’t enough, teenagers also have an increased exposure to violence, media stereotypes, changing family structures, changing gender roles, increased access to money, and greater access to tobacco, drugs and alcohol. Also, they may have oral practices that can be destructive to oral health, such as oral piercing, oral sex and bulimia. Dentists should always check for these.
We find that the biggest challenge in our office is communicating with the adolescent when all these changes are occurring. We constantly ask ourselves, “How do we motivate teens to re-commit themselves to high levels of oral care?” An understanding of the many changes in adolescents can guide us to better ways to communicate about a comprehensive prevention program.
In our practice, we asked the experts - the teenagers themselves. We created a teenage advisory board, which conducted a survey among teens about the best way to talk to teens. We’ve used the results to create a customized approach to communicating our prevention program to teens. We consulted with a psychologist who understands adolescent communication. We use new approaches based upon proven treatment models, follow up closely, and ask for feedback from the adolescent patients and their parents. We are constantly adjusting our approach to teens.
A few simple strategies have worked. Here’s how our practice tailored oral health messages for adolescent patients:
We developed successful communication strategies. Teenagers want to be treated like adults, even though we cannot assume that they have achieved their highest levels of cognitive or moral development. We use a consultative model, in which we communicate with the understanding that we know more, but we respect their decisions and parental input. We treat teenagers as adults, even though we realize they may not yet think as adults.
We avoid uncomfortable situations to which adolescents are keenly sensitive. Two specific areas are situations that embarrass them or highlight their dependence on adults. One example is discussing the need to call the patient’s parent for permission to schedule an appointment. Another is asking a teen in front of their peers if a parent should approve their appointments. Adolescents seek acceptance, especially by their same-sex peers, so we support their growing autonomy with themselves as well as others.
We support good decisions. The development of decision-making in young adults is complex and affected by many factors, such as knowledge, experience, advice seeking, goals, stress, peer influence, and health. Adolescents make their worst decisions when they are in groups, they have no adult input, and they are under time pressure. To minimize poor decision-making, we give young adults plenty of time to make decisions. We give them our honest input, support them in consulting their parents, and support their decisions based on their individual needs, not those of a group. We give them printed materials to help them think through their options and make decisions with no time pressure.
We set high expectations, and offer positive encouragement and follow-up. Teenagers do better in classes where teachers have high expectations. The same is true for our prevention programs. Letting them know we’re concerned about their health doesn’t need to be a barrier for our positive expectation of their treatment success. Adolescents like the idea of “self-treatment,” and this is exactly how we present our recommendations for proper home care.
We provide early diagnosis and patient recognition of the concern. Early detection of oral disease and prevention education in the earliest phases of puberty to pre-empt disease is ideal. It is good to educate patients and their parents even before the signs of oral disease are present.
During pre-puberty, kindly and sensitively tell your teen patients what may be ahead, and tell them how to prepare and prevent oral disease. Visual aids and intra-oral video cameras are great tools. Teenagers love technology, so an up-close view of their mouth can be very helpful. Emphasize that they have the ability to help prevent disease. Support them in taking responsibility for self-treatment of gingivitis and caries prevention at home. When you find disease, use it as a teaching opportunity, not a failure, to support their self-care.
Another good tool is aggressive conservative therapy. We support the earliest possible active intervention of oral disease. For two or more sites of incipient caries not yet in the dentin, and/or multiple sites of visible decalcification, we implement remineralization therapy with in-office fluoride treatments every four months, along with daily use of prescription-strength neutral sodium fluoride toothpaste. All pits and fissures are scanned with a Diagnodent to assist in the early detection of dentinal involvement, and sealants are placed if no decay is detected. Air abrasion and fissurotomy procedures are performed, and sealants or conservative restorations are placed when appropriate. All carious lesions in dentin are restored as soon as possible.
For moderate gingivitis, which we define as more than eight sites of bleeding with flossing, gingival redness and edema, and/or changes in contour and consistency, we use a four-month interval for professional prophylaxis and fluoride treatment, along with excellent home-care. For severe gingivitis, which we define as significant generalized bleeding upon provocation and/or multiple sites of gingival redness and edema, we use full mouth debridement with ultrasonic scaler and oral irrigation with chlorhexidine. This is followed by a six-week reevaluation. Home use of antibacterial agents such as special toothpastes and mouth rinses are prescribed on a customized basis. We use a four-month interval for the next hygiene visit until the gingivitis is resolved.
Education about available products works well with adolescents. Nearly all of them go to the drugstore for medicated skin creams and hair products, so it works to recommend tools and proven antimicrobial products. We have a “favorite picks” bulletin board that features products chosen by our young adult advisors, such as electric toothbrushes, flossing aids, and fluoride rinses and toothpastes.
The photos are typical of our observations regarding gingivitis. All cases shown are teenagers between the ages of 12 and 15 that had good home care and a history of no previous oral disease.
Another very popular recommendation for adolescents is Xylitol containing gum, which impacts Streptococcus mutans. Dosage is important, because four servings of gum a day can produce results, with the caveat that higher dosages can cause gastrointestinal upset.7 Various brands of the gum have different percentages of Xylitol. Our teen advisory board chose gum with the highest concentration of Xylitol available.
In conclusion, adolescence is a time of identity exploration. As women dentists, we can support lifelong preventive health decisions and overall well-being, all while enhancing self-esteem for our teen patients. In our practice, we are constantly learning from each other the best way to do that!
References
1. American Academy of Periodontology. Position paper. Periodontal Diseases in Children and Adolescents. J Periodontol 2003;74:1696-1704. (please have author check, as numbers didn’t make sense)
2. Bimstein, E, Matsson, L: Growth and development considerations in the diagnosis of gingivitis and periodontitis in children. Pediatric Dentistry 1999: 21:3.
3. Bimstein E, Matsson L, Soskolne AW, Lustmann J: Histologic characteristics of the gingival associated with the primary and permanent teeth of children. Pediatric Dent.1994. 16:206-10.
4. Modeer, T, Wondimu, B: Periodontal diseases in children and adolescents. Pediatric Dentistry. 2000.44:3.
5. Department of Health and Human Services. Oral Health in America: a report of the Surgeon General. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, National Institute of Dental and Craniofacial Research, 2000; NIH pub. #00-4713.
6. Simpson, AR. Raising Teens: A synthesis of research and a foundation for action. Boston, Massachusetts Center for Health Communication, Harvard School of Public Health, 2001.
7. Gutkowski, S. “The magic of Xylitol.” RDH, March 2004.
As supportive adults and health-care providers, women dentists can identify the life-tasks that adolescents must navigateAdjust to sexually maturing bodies and feelings Develop and apply abstract thinking and decision making skills Develop and apply new coping skills in areas such as decision making, problem solving, and conflict resolutionIdentify meaningful values and belief systemsUnderstand and express more complex emotional experiencesForm friendships that are mutually close and supportive Develop and apply a more complex level of perspective takingEstablish key aspects of identitMeet the demands of increasingly mature roles and responsibilitiesRenegotiate relationships with adults in parenting rolesDr. Sally Hewett maintains a private dental practice in Bainbridge Island, WA. She is the founder and President of the Young Adult Dental Affiliates, which supports adolescent oral health and empowers young adults in their communities. Dr. Hewett is the mother of 16 year-old Alisa. You may reach her at [email protected] and visit the young adult website at www.yada-nw.com.
