ORAL HEALTH

Marguerite DiMarco

Overview

Tooth decay or dental caries is one of the most prevalent chronic diseases in children, five times more common than asthma. Dental caries is an infectious disease that can be transmitted from mother or primary care taker to infant. Many health care professionals do not know about the pathology behind dental caries, or how serious oral disease can affect systemic health. In fact, the surgeon general called dental caries the “silent epidemic” especially affecting poor children. Many Americans lack a dental home and children are 2.5 times more likely not to have dental coverage. Dentists are declining, and many do not accept Medicaid, making it difficult for poor families to access dental care. Therefore, health professionals, including dentists/hygienists, physicians, physician assistants, nurse practitioners, nurses, and dieticians, need to work together to meet the oral health needs of infants, children, and adolescents (Office of Disease Prevention and Health Promotion, 2014).

Background

The primary cause of tooth decay is the bacterium Streptococcus mutans, which is the main contributor to tooth decay. Adults may have higher amounts of S. mutans in their mouths and can transmit it to their infant or child through the exchange of saliva. Frequent sugary snacking and drinking interacts with S. mutans, producing acids that can cause mineral loss from the teeth increasing the risk for tooth decay. Dental caries affects more children in the United States than any other chronic infectious disease. Tooth decay and other oral diseases that can affect children are preventable. Fluoride varnish can reduce cavities in preschool children by 30% to 40%. The American Dental Association (ADA) currently recommends 2.26% fluoride varnish for prevention of dental caries in children aged 6 years and younger. School-age children in second and sixth grades can have dental sealants placed on healthy molars, which has reduced the amount of caries in school-age and adolescent children. Unfortunately, the rates of caries continue to rise in the preschool-age group. Tooth decay in baby teeth contributes to an increased amount of decay in the permanent teeth (DiMarco et al., 2016).

Tooth decay of the front top teeth is referred to as early childhood caries (ECC), formerly called baby bottle tooth decay. The causes of ECC include poor oral hygiene, not enough fluoride, sleeping with a bottle or sippy cup, frequent snacking, bottle/sippy cup feedings containing beverages high in sugar, milk, or formula during the day or night, coating pacifiers with sweeteners like sugar or honey, and having a mother/caregiver or sibling who has had active tooth decay in the past 12 months. ECC and tooth decay in general are a multifactorial disease, and a child could have a few of these factors and not have decay, although other children may have only one factor and have decay. In addition, some foods called 81cariogenic foods such as cookies, juice or sweet drinks, chips, fruit roll-ups, and chewy candy cause tooth decay more than others. ECC develops in young children who use sippy cups or baby bottles constantly, and have poor nutrition with a history of eating frequently or eating the wrong foods (DiMarco et al., 2016).

The process of decay is influenced mostly by sugars that can be fermented by the bacteria in the mouth, causing a lower pH or acidic environment. This environment works on deteriorating the enamel of the tooth. This demineralization incites a cavity. Caries, in the primary dentition, leads to the same in permanent teeth. Another source of caries, aside from poor nutrition choices, is an infection. Mothers who pick up their child’s pacifier and put the pacifier in their mouth to clean it off may inadvertently pass on the bacteria, Mutans streptococci, which causes dental caries. Along with passing the infection by saliva and mouth kissing the baby, the frequency of eating significantly increases the presence of Mutans streptococci. The constant change of the acidity of the mouth’s saliva causes a wearing down of the protective enamel setting up the possibility of decay. A human’s saliva can cause remineralization of the tooth’s enamel. Eating foods that keep the acidity of saliva high continues to cause demineralization and the potential for dental caries. The more the teeth are bathed in anything other than water or healthy saliva, the greater the chance of demineralization. Despite our understanding of the risk factors associated with caries in early childhood, it remains one of the largest untreated conditions in preschool children (Griffin et al., 2014).

Oral health has been linked to physical health, social acceptance, and well-being. During these early years of physical growth, appropriate nutrition is essential. If chewing is painful, children refuse to eat crunchy fresh fruit or vegetables because they cause too much discomfort. Socially, children are sensitive to being different from others. If teeth are decayed or eroded, it sets them up for social bullying, even at a young age. The normal eruption of teeth permits children successful language development. Proper speech, sturdy teeth, and attractive smiles permit children greater access to their social worlds and help them achieve not only physical health but social acceptance as well. Lack of access to care and untreated dental conditions in children contribute to emergency room visits, expensive treatments, dysfunctional speech, compromised nutrition and growth, and an estimated 52 million missed hours of school per year, 189 million hours of lost work, not to mention the pain and suffering. Untreated caries can lead to infection, and infections in the mouth can spread to the blood causing infections in the brain, mouth abscesses, sinus infections, cellulitis, endocarditis, and sepsis to mention a few. Unborn babies are affected if their mothers have dental disease and periodontal disease; the infant could be born having a low birth weight, be premature or even still born (Norris, DiMarco, & Thacker, 2013).

Clinical Aspects

The American Academy of Pediatric Dentistry (AAPD) and the American Academy of Pediatricians (AAP) recommend that primary care providers and other health professionals include the following oral health prevention 82strategies: (a) perform periodic risk assessments to determine the child’s relative risk of developing dental caries; (b) provide anticipatory guidance to parents about oral hygiene, diet, and fluoride exposure; (c) apply appropriate preventive therapies, such as fluoride varnish; and (d) help parents establish a dental home for their children by 12 months of age (Griffin et al., 2014).

ASSESSMENT

Nurses can perform an oral-screening assessment of the lips, tongue, teeth, gums, inside the cheeks, and the roof of the mouth to assess for dental caries or other oral conditions such as abscesses or trauma. An oral health screening takes about 2 minutes; no diagnosis is made that requires a dentist, and the nurse can guide management. The nurse can do a knee-to-knee examination with the parent facing him or her and the child lying down on the nurse’s and parent’s knees facing the parent. With a gloved hand, the nurse lifts the lip, views the soft tissue, the teeth, and the entire mouth. Any light such as a flashlight can be used for screening. A tongue blade or tooth brush can be used to move the tongue and view the teeth (Norris et al., 2013).

NURSING INTERVENTIONS, MANAGEMENT, AND IMPLICATIONS

Anticipatory guidance to parents and the child should be given not only during well-child examinations but also in the hospital when doing an oral examination and/or brushing the child’s teeth. Children who are at high risk are special-needs children, children with cancer, and/or children on ventilators. Nurses should follow special hospital procedures to prevent ventilator-associated pneumonia (VAP) with children on ventilators. Oral care with chlorhexidine has been studied, and meta-analyses suggest that oral care with chlorhexidine can reduce VAP rates in this population by 10% to 30%. The American Dental Association recommends beginning oral hygiene a few days after birth. Wipe the gums with a gauze pad after each feeding to remove plaque and residual formula that could harm erupting teeth. When teeth erupt, brush them gently twice a day with a child-size toothbrush and water. Fluoride toothpaste is recommended for children older than 2 years. After oral hygiene, rinse and suction the mouth. Keep the oral mucosa and lips clean, moist, and intact using sponge-tipped applicators dipped in nonalcohol nonperoxide mouth rinse (Klompas et al., 2014). Here are some tips for well or stable children:

     1.   Have your very own toothbrush that no one else uses.

     2.   Brush at least 2 minutes twice a day (after breakfast and before bed) with an adult brushing the child’s teeth before bedtime until age 7 years.

     3.   Use a smear of fluoride toothpaste on a soft toothbrush until child spits well.

     4.   Once able to spit well and not swallow, increase fluoride paste to a small pea size or the size of the child’s smallest fingernail.

     5.   Drink water after eating sweets to rinse off the teeth.

     6.   If a toddler carries a sippy cup around while playing, fill with water only.

     7.   If going to bed, fill bottles or sippy cups with water only.

     8.   Be cautious, if nursing your baby, that you take the baby off the breast once asleep.

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