Download Pediatric Patient Competency- EB

Foothill Dental Hygiene Program
Pediatric Competency
Spring 2016
Alysha Prevost
Introduction
EB is a four-year-old Caucasian male. He lives in Santa Clara, CA with his parents. The city of
Santa Clara is provided with fluoridated water. EB is moderately active, participating in baseball
league; in addition EB also enjoys reading. He has healthy eating habits provided by his mom
and dad, and his grandparents who watch over him on weekdays who also live in Santa Clara,
CA. EB’s grandparents are responsible for his oral care in the morning and provide him breakfast
and lunch five days a week. His parents are responsible for all other meals and his nightly oral
health routine. EB favorite foods are pizza and cereal. EB’s mom brought him to his first
appointment and his grandfather brought him to his second appointment. The mother was helpful
in answering all the initial questions at the first appointment and the grandfather signed EB
treatment plan, both over saw his oral health education. EB is at the unawareness stage of the
learning ladder and does not understand why he cleans his teeth on a daily basis. He is a visual
learner and does not mind asking question to further understand a concept.
CASE PRESENTATION
Medical/Dental History
EB last medical exam was in April 2016 and his last dental exam was in March 2016 this was the
second time seeing the dentist. He has no medical conditions, all vitals were within normal
limits, and he does not take any medications. The extraoral and intraoral examination was within
normal limits, and the only atypical finding was he had tight labial frenum. EB’s gingiva
appeared generalized pink with firm consistency, and flat papilla.
Caries and Periodontal Risk Assessment
EB has low risk for caries and low risk of periodontal disease. He has numerous protective
factors against caries, such as living in a fluoridated community, uses fluoridated toothpaste
twice daily, application of fluoride varnish in the last 6 months, and has adequate saliva flow. EB
has some predisposing factors for caries such as frequent snacking and deep pits and fissures. His
enamel defect on #E has been there since birth and has remained stable. EB had no additional
demineralized areas I felt it was appropriate to put him in low disease risk when looking at his
balance between protective and predisposing factors for caries. Plaque index is good with a score
of .54 and his dmft score is zero. No probing depths were taken, light calculus, and localized
slight marginal plaque on the posterior teeth. His Previsor risk scores were very low risk for
caries and very low risk periodontal disease with an AAP type 1. EB has not had radiographs
taken at this time.
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Dietary Evaluation & Nutritional Counseling
Dietary analysis was done to understand EB nutrition, his family kept a dietary journal for five
days and was told to include all his meals, snacks, and beverages. The information was imported
into Supertracker.usda.gov and showed the five food groups; grains, fruits, vegetable, dairy, and
proteins. The results were compared with the recommendations established by MyPlate.gov,
provided by the USDA. EB met all his dietary recommendation and over exceeded in his amount
of protein, fruits, and grains, seen in Figure 1.
EB’s grandparents and his parents are responsible for EB’s nutrition and have a good
understanding of nutrient rich foods. Even though, EB over exceeded in multiple food groups EB
has a normal BMI. Overall, EB eats very healthy foods that are low in fat and sugar. Consuming
proteins that are lean or low fat such as white fish. When looking at his fruit intake his snacks
were non-processed such as apple slices, strawberries, and grapes. But I did note that he did
double his recommendation in fruits so I suggested that it could be beneficial to replace some of
the fruit consumed with vegetables. He eats whole grains such as whole-wheat pasta and wholewheat bread. His dairy was adequate meeting the USDA food recommendations this is
important because dairy product provide calcium which helps promote strong bones and healthy
teeth. EB drinks whole milk daily and snacks on cheese stick occasionally. EB’s sweet score was
low. This is true because the foods he was eating were not sticky, causing more minimal acid
exposure. As a dietary recommendation, I suggested rinsing with water after eating to remove
food particles and make a more balanced ph level.
Proteins (oz)
Dairy (cups)
Actual
Fruits (cups)
Recommended
Vegetables (cups)
Grains (oz)
0
2
4
6
8
Figure 1
Treatment Plan
EB and his mom’s chief complaint was that they want to keep EB’s teeth healthy. EB had
localized slight marginal plaque and some light calculus; my goal was to teach both him and his
mom how to floss with a floss holder and for them to report using the floss holder by second
visit. In addition, I wanted both EB and his mom to understand the link between plaque biofilm,
calculus, and periodontal disease and for them to explain the link between them by the end of the
second visit. EB is a frequent snacker, which can affect his caries risk in the future so I set the
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goal of EB and mom to understand the link between caries and nutrition and for them to report
rinsing after snacking by the end of the first visit. In addition, I would like EB and his mom to
understand the importance of fluoride use to reduce caries with an outcome of EB and mom
using fluoridated toothpaste twice daily. Lastly, I set the goal for EB and his mom to learn the
Fones’ toothbrushing technique to decrease plaque. My goal was to have EB and his mom to
demonstrate by the end of the second visit. The mother was very interested in the goals that I set
and asked many questions to fully understand. EB was also very excited to learn the oral health
care technique such as flossing with the floss holder and brushing with the Fones’ technique.
After disclosing and OHI, I deplaqued with a UC and then applied fluoride varnish.
Patient Education
EB and his care team have good oral hygiene practices shown by evidence of his current oral
health status. His grandpa is responsible for brushing his teeth in the morning and his mom is
responsible for brushing his teeth at night and flosses once daily with a floss holder. EB is
unaware of why he brushing and flosses each day. My goal was to enhance EB’s oral hygiene
skills and to educate him on the importance of preventing disease with good oral hygiene care. I
choose to teach EB the Fone’s toothbrushing technique, this technique is used for individuals or
children with a lower level of dexterity. It was important for me to give positive feedback to EB
on his current practices because he is doing a great job. I would not want to discourage him by
overwhelming him with a new technique that he is not interested in. So with his permission, he
let me review the Fone’s toothbrushing technique that would give EB the basics to start
becoming more engaged during his oral health home care practices. Stated at his first
appointment, was the fact that he has not practiced brushing his own teeth. His parents and
grandparents completely brush him teeth for him. I thought it was important to start building on
his self oral hygiene care as soon as possible. I suggested having EB brush first with the
supervision of his mom or grandpa then for them to brush his teeth after. This way he can
practice and his mom or grandpa can get the places he may have missed.
I reviewed with EB why is it is important to have good oral hygiene by teaching her about
gingivitis and its connection with periodontal disease. We discussed how gingivitis starts by
bacteria causing an inflammatory response in his gums that causes tissue. When explaining these
two concepts I used a flip chart so he could see pictures of the disease progression. EB and his
grandfather that was their for his OHI during the second appointment seemed to be interested in
connection between the two diseases. In the future I will need to find a better way to describe the
caries process, the flip chart worked great for the disease progression of periodontal disease but
was not great for describing the demineralization process. Cavities peek EB’s interest and I could
have provided more education about how the “tiny holes” in your teeth get there. After
explaining inflammation to EB, I showed him how to brush using the Fone’s toothbrushing
technique on a typodont after had him demonstrate. During his demonstration I made suggestions
and gave positive feedback. Next time when I am giving an OHI I will make sure that I let my
patient demonstrate first, this way I can see their current ability’s and technique. I missed an
important step by not seeing his current toothbrushing skills. Since he is a visual learner, I
planned to use a “2- Tone” disclosing agent to see which areas have been neglected. It was a
good indication of where the old plaque biofilm was and what areas could be improved. EB was
excited to demonstrate in his own mouth, this caused him to brush very quickly and unorganized.
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I adjusted his hand to control the movements making them more circular and slower, also
encouraging him not to brush with any force. I told him that he did very well and showed him
that he removed plaque from that area. EB was excited to try to use this new technique at home.
Overall I want to encourage EB, his mom, and grandparents to keep up the good work with the
oral hygiene care and his nutrition.
After the oral hygiene instruction (OHI), I received feedback from the instructor giving me some
insight on how I can improve as well as some of my strengths during my patient education. I
would like to work on explaining the gingivitis and periodontal process in simpler terms. It was
hard to explain a more advanced disease state, such as periodontal disease to a child EB’s age. I
will also have to work on developing more appropriate vocabulary for not only a four-year- old
but also any person that is not familiar with dental terminology. I can strengthen my
communication by finding alternative words and visuals that can describe the processes more
clearly. In addition, I felt I could have given both EB and the grandpa a chance to ask more
questions during my OHI. Especially, while reviewing key points in order to gauge if my patient
understood me. Overall, I felt that EB and his grandpa learned the Fone’s technique and it will be
used in their household and that they left knowing quite a lot more about oral health and its
connect with oral disease processes.
Research
It was mentioned in during the first appointment
that EB was born a premature baby. EB also has
an enamel defect found on #E facial and lingual
surfaces seen in Figure 2.
Enamel defects in primary detention can be a
common occurrence relating to preterm infants1.
Defective development of enamel (DDE) caused
by the trauma to the tooth buds of the maxillary
incisors in development at birth1. This trauma to
the oral cavity is done after birth during neonatal
intensive care1. Neonatal intensive care is often
needed for a premature infant to survive and is
believed to be one of the most challenging aspects
of neonatology1. One of the intensive procedures
Figure 2.
used to give respiratory support to a preterm
infant is tracheal intubation1. This procedure is recommended in children with apnea, respiratory
distress syndrome, sepsis, patent ductus arteriosus, human parainfluenza viruses, meconium
aspiration syndrome and preoperative1. Tracheal intubation has been linked to causing some oral
defects such as oral lesions found on the buccal mucosa, the hypoglossal nerve, lingual nerve,
fractured teeth, defective development of enamel (DDE), disruption of the dental crown, and
dental malformations1.
People at risk for DDE are children that were born preterm and received tracheal intubation1. At
the beginning stage of life at which these infants are born preterm their deciduous teeth are in the
late bell stage at this time the organic matrix is being formed which is mineralizing the tooth’s
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enamel1. Usually at this time the teeth will be more prone to injury because it lacks the protection
of bone deciduous tooth germs at birth1. The infants that have undergone intubation have a
higher prevalence of DDE at 85%1. A disturbance during this stage is shows a clinical
manifestation of hypoplasia or hypomineralization of enamel1. The teeth most affected with
hypoplasia defects are the upper right central incisor, lateral incisor, and upper left quadrant1.
This area corresponds with the positioning of the laryngoscope, which puts pressure on the
gingival mucosa, teeth, and lips1. The amount of time with intubation maybe a factor, in the
research they found a significant difference when comparing infants that showed DDE and not1.
The median time of incubation with those who had DDE had an incubation time of 3.5 days
verse the infants without DDE showed a median time of intubation of 2 days1. This variable
shows that the greater number of days intubated, the greater chance of DDE1. Premature babies
with a gestational age between 23 and 31 weeks had more of a prevalence of DDE due to the fact
that they were intubated longer causing more trauma to the forming incisors1.
Hypomineralization is usually found in the first permanent molars and can be associated with the
permanent incisors2. These abnormalities can be found in the translucency enamel can be seen as
white to yellow brown discolorations on the tooth surface2. Due to the hypomineralizion the
enamel becomes weakened causing trauma such as fracture due to masticatory forces2. These
areas can also be painful making it hard for individuals to carry out adequate plaque biofilm
removal during self oral hygiene care2. These hypominalized areas are at high risk for
demineralized2. Research suggest using 5% fluoride varnish weekly over a one month period
may prevent with the addition of oral hygiene instruction can reduce structural loss of the
hypomineralized area3. After fluoride treatment, a gloss ionomer cement (GIC) can be placed
which can protect the demineralized area while providing an enviorment that facilitates the
mineralization process3. In addition, it protects the remaining structure from caries lesions
formation and tooth sensitivity3.
Fluoride therapy is often used to reduce caries risk and provides a demineralization effect4. The
enamel can be made resistant to acid when fluoride is absorbed into the tooth’s structure along
with calcium and phosphate4. Fluoride can be ingested found in different foods like raisins,
cereal, and chicken and beverages such as fruit juices, wines, and bottled water4. The Center for
Disease Control (CDC) recommends that communities with fluoridated water should be at the
acceptable level of .7 parts per million (ppm)4. Topical fluoride can be delivered in various
fluoride concentrations or ppm offering different strengths for; over-the counter self-applied,
prescription strength in which the client applies at home themselves, and professionally applied4.
The use of fluoride products on children must be limited because excessive ingestion of fluoride
can cause chronic toxicity of fluoride such as fluorosis4. In addition, swallowing of these
fluoridated products within a short period of time can cause acute toxicity, which can cause a
mild reaction such as vomiting, abdominal pain, and nausea to very serve reaction such as death4.
Clinicians should use special precaution when suggestion fluoride dentifrices to children under
six, they may not be at the age in which they can priory expectorate4. Use of a fluoride varnish,
which has a high-potency or pmm, and is used less frequency maybe indicated with children
whom cannot use at home fluoridated products4. These topical fluoride products are for in-office
only due to there high-potency they the potency of 9000ppm if the fluoride agent is 1.23%
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acidated phosphate fluoride or as high as 22,600ppm if the fluoride agent is 5% NaF and have
been shown to reduce caries by approximately 30%4.
Each fluoride product varies in potency and the number of time used either daily or every couple
of months. Over-the-counter (OTC) toothpaste varies in fluoride concentration having anywhere
from 1000 to1500 ppm and offers different fluoride agents for example .1% sodium fluoride
(NaF) or .1% sodium monofluorophospate (MFP) and should be applied twice daily4. In
addition, fluoride mouth rinse with 230ppm found in 0.05% NaF rinse in products like Act offer
a low-potency that can be used once daily4. These low-potency fluoride mouth rinses have been
showed to reduce the risk for caries be 30% to 35% when used daily and when users follow the
manufactures instructions on product4. Prescription fluorides mouth rinses may be indicated for
patient that are moderate to high risk for caries such as individuals with present caries, white spot
lesions, xerostomia, orthodontic appliances, and exposed roots4. Prescription fluoride rinses offer
a higher ppm compared to the OTC mouth rinses containing around 1000ppm, which can vary
from product to product4. Prescription gels and paste should be used for with a high to extreme
risk for caries like individuals with special needs, xerostomia, individuals receiving head and
neck radiation treatment, and those with dentinal sensitivity4. Fluoride prescription products in
the form of gel or paste can be applied by brush or in a custom tray after tooth brushing, these
product contain 5000ppm with the fluoridated agent being 1.1% neutral NaF or 1.1% NaF and
acidulated phosphate fluoride4.
Reflection
When preparing for my pediatric patient, I knew I could only prepare so much. What I could not
prepare for was what I would find during my assessments and more so if the child did not want
to be at the dental office it maybe hard to change his mind. At EB’s last dental visit he became
very unhappy to be there and got very upset. I was not told the reason for his reaction but I
would guess it was his nerves or fears. Knowing this, I prepared for is appointment by learning
what EB likes, cars. I brought him dollar store easers that were shaped as cars, this eased the
appointment at each major milestone in treatment. This taught me it pays off learning about my
patient’s likes and dislike prior to our appointment. In my future clinical practices I will make it
part of my routine reading chart notes to learn my patients preferences. In addition, I think it is
important if someone confesses their fears of going to the dentist that the dental hygienist asks
why, so they can ease and avoid their fears. I felt I taught EB that there was nothing to fearful of
during his care. EB taught me that pediatric dental care was nothing to be nervous about.
Pediatric patients may have their own challenges but they can truly enjoyed the learning
experience.
During my OHI learned it is important to take your time when explaining various subjects. By
taking my time, I really mean breaking up each subject more. For example EB was more
interested in the caries process so I could have made sure he understand it by asking him
questions after my explanation. I needed a stronger way of explaining how “germs” can hurt
your teeth and cause cavities. In order to teach the relationship between caries and plaque in a
stronger way I should have used a story acts as an analogy so a four-year-old could better
understand a larger concept. By spending more time at the end of this large concepts EB could
felt less overwhelmed at the end of the complete OHI. When giving my next OHI I will focus on
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using more concise language, my vocabulary was skipping around too much using multiple
words to describe similar things like bacteria, germs, and plaque. My OHI started with my using
the words germs and bacteria then I switched to plaque. It is important for me to use the same
familiar words when educating any patient.
For my next pediatric patient that comes in I would still like a family member to be present. The
family members that were in the clinic with EB I kept him focused. They told him to pay
attention when I was talking to him, which would have been difficult for me to do. They also
helped me keep the patient still when I was cleaning his teeth by telling him not to fidget. I felt
that the parents were the greatest aid to keeping EB cooperative. His parents and grandparents
prepared him prior to our appointment by telling EB what to expect during his appointment.
Overall, EB was a great introductory pediatric patient and I feel more prepared to give care to
children in the future.
References
1. Falcao NS, de Olivera M, Guimaraes RP, da Silva C, de Lima AA. The neonatal
intubation causes defects in primary teeth of premature infants. Biomed Pap Med Fac
Univ Palacky Olomouc Czech Repu. 2014. 158 (4): 605-612 [Cited 2016 Jun 7].
Available from: http://biomed.papers.upol.cz/artkey/bio-2014040018_The_neonatal_intubation_causes_defects_in_primary_teeth_of_premature_infants.
php
2. de Oliveira DC, Favretto CO, Cunha RF. Molar incisor hypomineralization:
Considerations about treatment in a controlled longitudinal case. J Indian Soc Pedod Prev
Dent [serial online] 2015 [cited 2016 Jun 7];33:152-5. Available
from: http://www.jisppd.com/text.asp?2015/33/2/152/155133
3. Fragelli CMB, de Souza JF, Jeremias F, Cordeiro R, Santos-Pinto L. Molar incisor
hypomineralization (MIH): conservative treatment management to restore affected teeth.
Brazilian Oral Research. 2015 Jun 16; 29(1).
4. DarbyML,WalshMM. Dental Hygiene Theory and Practice. 3rd ed. Dolan, John J. St.
Louis (MO): Saunders Elsevier; 2015.p. 580-591.
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