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Transcript
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. Prevost 1 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 Prevost 2 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. Prevost 3 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 Prevost 4 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% Prevost 5 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 Prevost 6 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. Prevost 7