DCA06DT Dental Treatment of Pediatric and Adolescent Patients _ __________________________________
bacteria resistant to fluoride are known to inhabit the oral cavity (and the environment) in response to fluoride exposure [70]. Fluoride is nonselective and also kills many species of beneficial bacteria. Topical fluoride inhibits the demineralization of sound enamel and promotes the remineralization of damaged enamel, particularly in the context of dietary fluoride, calcium, and phosphorus deficiency [26]. Fluoride, calcium, and phosphate strengthen the crystal structure of enamel [28]. Beyond a topi- cal effect, ingested fluoride will become incorporated into the enamel and dentin of unerupted teeth and thus increase their resistance to susceptible cariogenic bacteria [22]. New research indicates another important caries-preventing action of topi- cal fluoride is to weaken the ability of bacteria to adhere to tooth enamel [73]. Fluoride concentrations in community water supplies in the United States are not standardized, and some communi- ties have opted not to include fluoride in their water at all. The American Academy of Pediatric Dentistry recommends age-dependent fluoride supplementation only if the fluoride concentration in a child’s water supply is less than 0.6 parts per million (ppm) [31]. No fluoride supplement is recommended for children from birth to 6 months, even if community water fluoridation is unavailable. A 0.25-mg fluoride supplement is advised for children 6 months to 3 years of age if the fluoride concentration in available water is less than 0.3 ppm. Chil- dren 3 to 6 years of age should receive 0.50 mg fluoride if the water fluoride concentration is less than 0.3 ppm or 0.25 mg fluoride if the concentration range is 0.3–0.6 ppm. Children 6 to 16 years of age should receive 1 mg fluoride supplement if the fluoride concentration in the community water supply is less than 0.3 ppm or 0.50 mg if the fluoride concentration is 0.3–0.6 ppm [31]. The American Dental Association Coun- cil on Scientific Affairs encourages healthcare providers to evaluate all potential fluoride sources and to conduct a caries risk assessment before prescribing fluoride supplements [74]. Parents should consult with their pediatrician, pedodontist, or general dentist to determine if fluoride supplementation is needed for their child. Due to increasing research and public awareness of the neu- rotoxic effects of many chemicals, including fluoride, some parents will not want to administer fluoride supplement or fluoride toothpastes. These parents should be advised regard- ing proper nutritional intake of calcium, phosphorus, and vitamin D and the importance of regular tooth brushing and preventative dental visits [74]. An alternative to fluoride for enamel protection and tooth remineralization is calcium hydroxyapatite, a calcium and phosphorus (phosphate) mineral of which 70% to 80% of tooth and bone are composed. Topical preparations containing hydroxyapatite have been shown to be as or more effective for remineralization, treating tooth hypersensitivity, and reversing carious lesions than fluoride and do not have the detriments
of toxicity or fluorosis [84]. Other effects of hydroxyapatite are absorption of oral pathogens and protection against stains and biofilm attachment. The most effective type of hydroxyapatite for topical use is the nanocrystal form (nanohydroxyapatite), which is readily available as toothpastes and rinses. Calcium hydroxyapatite is available as a nutritional supplement and is also included in some dental gels and varnishes. DENTAL EXAMINATIONS AND PROPHYLAXIS APPOINTMENTS As noted, children and adolescents are entirely dependent upon their parents or caregivers for access to dental care, and issues with transportation and financial stress may arise. However, regularly scheduled dental examinations can provide a means for oral hygiene instruction for children and their parents and can allow for identification of carious lesions early, when they can be restored by conservative and less expensive means. Beyond the cost-effectiveness of preventive pediatric dentistry, this approach reduces the suffering and morbidity associated with advanced dental problems. Dental insurance coverage and family income may impact access to care. Families in need of financial assistance may be eligible for dental coverage under the Medicaid program. Unfortunately, the low reimbursement fee schedule for den- tal procedures precludes many general dentists and dental specialists from accepting patients under this program. The dental divisions of county health departments may provide another low-cost source of dental treatment for pediatric and adolescent patients. Some county and state dental societies also provide periodic pro bono services to those in need. Access to adequate dental care is essential for the appropriate development of children’s oral and general health and for their ability to develop and maintain a healthy sense of self-esteem, making this a public health issue. MEDICATION USE IN PEDIATRIC AND ADOLESCENT DENTAL PATIENTS Local anesthetics, analgesics, and antibiotics are used most often before, during, and after the dental treatment of pediatric and adolescent patients. As with any patient, a thorough medi- cal history must be obtained and discussed with the patient and his or her parent or guardian prior to using any medica- tion. Some states require written parental/guardian consent for any medication use in minor children. Medications used for dental purposes should be carefully selected and used to ensure they do not interact adversely with those prescribed to treat a systemic disease. If there are any medical issues that would cause a concern with a proposed dental treatment or the medications used, consultation with the patient’s pediatrician or another physician is recommended.
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