Adolescent Oral Health

Protecting All Childrens Teeth
Oral Health in
Adolescence
www.aap.org/oralhealth/pact
Introduction
Continued focus on oral health during the adolescent period is
important.
Many childhood risk factors persist and new oral health risk factors
may emerge during adolescence. Opportunities exist to prepare,
educate, and empower adolescents to take control of their oral
health as they move toward adulthood.
Because adolescents often have an increased focus on personal

aesthetics, this can provide an opening to discuss oral health
knowledge and behaviors during office visits.
Learner Objectives
Upon completion of this presentation, participants will be able to:
List common risk factors for dental caries during adolescence.

Define periodontitis and gingivitis and state clinical signs, risk
factors, and anticipatory guidance regarding periodontal disease.
Discuss the prevalence of tobacco use among US adolescents
and oral effects of tobacco.
Recall the adverse oral effects of methamphetamines and
marijuana.
List common signs of oral cancer.
Cite the AAP and AAPD stand on oral piercings and counsel a
patient on the risks associated with oral piercings.
Dental Caries
52% of 12- to 19 year olds have experienced tooth decay in at
least 1 tooth and 13% of adolescents have untreated caries.
The pit and fissure surfaces of the molars are the most common
site of caries.
The dynamic caries balance continues throughout adolescence,
and the same factors that influence caries risk in children still exist
in adolescence.
Dental Caries, continued

Health care providers should be mindful of the following risk factors for
dental caries in adolescents:
Inadequate access to fluoride (especially topical fluoride)

Poor oral hygiene
Frequent access to sugars and acids
Sweetened sugar beverages including soda, sports drinks and juice
Sugared beverage consumption is also a risk for obesity and osteoporosis

(especially in females)
Sour candy and sticky snacks
Previous caries experience

Reduced salivary flow
Dental Caries, continued
Special health care needs
Infrequent professional dental care
Risk factors that may first be noted in the adolescent, include

eating disorders and orthodontic appliances that make performing
oral hygiene more difficult
Anticipatory Guidance
Anticipatory guidance in caries prevention for adolescents is similar
to that of young children:
Encourage fluoridated water intake.
Recommend fluoride supplementation for high risk teens not

having access to fluoridated water (up to age 16).
Encourage fluoridated toothpaste use twice a day.
Encourage daily flossing.
Anticipatory Guidance, continued

Encourage and assist in referrals for dental visits that can provide
preventive strategies such as dental sealants, topical fluoride, plaque
and calculus removal, and restorative measures.
Promote a healthy diet with rare snacking on sugary or acidic foods
and liquids. Counsel on risk of vending machine options as these are
often placed in locations that teens frequent.
Encourage and empower parental assistance in oral hygiene for
adolescents with special health care needs.
Gingivitis
Gingivitis is gingival (gum) inflammation
due to the build-up of plaque on
tooth surfaces.
Symptoms of gingivitis include red and
swollen gums that easily bleed with
brushing or flossing.
Antonio Moretti, DDS, MS Associate Professor, Department of
Periodontology. UNC School of Dentistry
Gingivitis is usually the result of suboptimal oral hygiene, both

inadequate brushing and flossing.
Periodontitis
Periodontitis is usually accompanied by gingivitis but is a distinct
disease process that involves irreversible destruction of the supporting
tissues surrounding the tooth, including the alveolar bone.
Plaque and tartar accumulate at the gum line and the resultant
inflammation leads to formation of a periodontal pocket between the
gums and the teeth.
The infection and inflammation spread from the gingiva to the

periodontal ligament and alveolar bone that support the teeth. The
destruction of support causes the teeth to become mobile and, if left
untreated, can lead to tooth loss.
10
Signs and Symptoms of Periodontal

Disease
11
Gums that are swollen, bright red,

and tender to touch
Gums that bleed easily
Gingival recession
Tooth Loss
Loose/mobile permanent teeth
Both hormonal changes and external
factors can affect the periodontal
tissues of the adolescent
Gingival Recession
(affecting the mandibular anterior teeth)

Localized Aggressive Periodontitis
Usually begins at onset of puberty

Alveolar bone loss usually affects incisors and 1st molars
Destruction of supporting tissues = high risk for tooth loss
Signs can include tooth mobility and migration (increased spacing
between teeth)
Can occur without obvious inflammation (gingivitis) or other
signs/symptoms
Disease typically progresses very quickly
Clinical and radiographic exam by a dental team is very important
Intra-oral condition is not necessarily linked to any systemic

disease
Genetic predisposition (family dental history should be
evaluated; siblings should be examined)
Destruction can either arrest or progress and affect more teeth
and become Generalized Aggressive Periodontitis (can affect
the entire dentition)
A specific group of bacteria have been associated with this
disease, so dental treatment typically includes antimicrobial
therapy
Arrows indicate sites with significant alveolar bone loss
14
Photos courtesy of:

Risk Factors for Periodontal Disease

Poor oral hygiene resulting in plaque and calculus formation
Gingivitis or gingival recession
Can be triggered by abrasions from oral piercings
Systemic conditions:
Down syndrome
Immunodeficiency (e.g., cyclic neutopenia, leukocyte adhesion
deficiency)
Metabolic diseases (e.g., diabetes, hypophosphatasia)
Oncologic (e.g., leukemia, Langerhans cell histiocytosis)
Tobacco or marijuana use

Pregnancy and hormonal contraceptives
Oral trauma
15
Periodontal Link to Systemic Disease

Periodontitis may be an independent risk factor for:
Cardiovascular disease (stroke and coronary heart disease)
Diabetes (glycemic control, diabetes complications, and development
of type 2 diabetes)
Adverse pregnancy outcomes (i.e., low-birth weight, premature birth)
Association with multiple other systemic diseases (cancer, arthritis,

obesity, metabolic syndrome, chronic kidney disease) has been
studied, but study size, limitations, and confounders prohibit
statement of causal connection at this time.
Additional studies are warranted to investigate these associations.
16
Periodontal Disease
Prevention and Treatment
Reinforce the importance of good oral hygiene, encourage brushing
and flossing.
Discourage all forms of tobacco and other drug use.
Discuss the risks of oral piercings.
Promote regular preventive dental visits.
Maintain vigilance regarding the oral health of adolescents with
special health care needs.
Incorporate an evaluation of hard and soft oral tissues into every
routine physical examination.
Refer patients with abnormalities to a dental professional and
continue close monitoring.
17
Trauma
Adolescents are at increased risk for trauma to the mouth and
teeth because of their active lifestyle and increased risk-taking
behaviors.
Oral and facial trauma can occur secondary to falls, violence,
athletics, or motor vehicle and other accidents.
18
Risk Factors for Oral Trauma
Compromised protective reflexes or poor coordination (children

with special health care needs)
19
Lack of use of protective face and mouth gear for athletes
Substance abuse (by the adolescent or within the family)
Child abuse or neglect
Malocclusion with protruding front teeth
Hyperactivity
Oral piercings
Tobacco
Consider the prevalence of tobacco use among teenagers in the
United States (2009 study):
26% of high school students report some tobacco use (cigarettes,

smokeless tobacco, cigars).
20
19.5% of high school students were current cigarette smokers.
14% of high school students reported cigar use.
8.9% of all high school students used smokeless tobacco.
Oral Effects of Tobacco

Tobacco has a direct carcinogenic effect on the epithelial cells of the
oral mucous membranes and may cause oral cancer.
Tobacco can also have the following oral effects:
Tooth stains and discoloration
Halitosis
Calculus formation
Encouraging patients to quit smoking or using chewing tobacco can

have positive effects on both their general and oral health.
21
Illicit Drugs
Illicit drug use can have negative effects on oral health by

affecting salivary flow, changing the acidity of the mouth, and by
promoting poor dietary habits and laxity in oral hygiene.
22
Methamphetamines
Street names: Crystal meth, meth, speed, ice, crank.
Potent central nervous system stimulant that stimulates release
and blocks re-uptake of monoamines in the brain.
Can be smoked, snorted, injected, or taken orally.
Rampant caries progression, termed meth mouth, may result from
a combination of drug-induced xerostomia, increased consumption
of high calorie, sugared, carbonated beverages, tooth grinding and
clenching, and poor oral hygiene.
23
Meth Mouth
Signs of meth mouth include:
1. Accelerated tooth decay in teens
and young adults.

2. Distinctive pattern of decay on
buccal smooth surface of teeth and
interproximal surfaces of anterior
teeth.
3. Malnourished appearance of user.
24
Used with permission from the American Dental Association
Meth Mouth, continued
If meth mouth is discovered:

1. Encourage the patient to stop using the drug, ask if they would
like help quitting, and assist them in finding help.
2. Encourage good oral hygiene.
3. Refer to a dentist for evaluation and management.
25
Cannabis
The oral health effects of cannabis are similar to tobacco and include:
26
Gingivitis and periodontal disease

Oral cancer
Xerostomia
Oral Cancer
Approximately 30,000 Americans are diagnosed annually with oral
cancer. In the 15-24 age group, there are 30 deaths per year.
Approximately 75% of oral cancers are related to tobacco use,
alcohol use, or both.
Tobacco use in any form (cigarettes, cigars, chewing tobacco) can
cause oral cancer.
27
Signs and Symptoms of Oral Cancer

1. Oral tenderness, burning, or a sore that does not heal
2. Pain, tenderness, or numbness in the mouth
3. Lump in the mouth
4. Color changes in the mouth
5. Difficulty chewing, swallowing, or speaking
6. Change in the way the teeth fit together
7. Leukoplakia
Providers should encourage and assist in tobacco cessation, as well as
examine the oral mucosa for abnormalities, especially in tobacco-using
patients.
28
Oral Piercings and Grills
The American Dental Association and the American Academy

of Pediatric Dentistry have officially recommended against
intraoral/perioral piercing and tongue splitting because of the
potential for numerous negative sequelae.
29
Procedure-Related Risks
Swelling
Infection
Oral piercing carries a risk for infection due to trauma of the skin or
oral tissues and the vast amount of bacteria in the mouth.
Blood-borne disease transmission - Possible transmission of Hepatitis
B, C, D, or G if the procedure is performed in non-sterile manner.
Endocarditis
Oral piercing is a route of entry of bacteria into the bloodstream

May result in endocarditis for patients with cardiac abnormalities
Prolonged bleeding and possible nerve damage
30
Jewelry-Related Complications
Used with permission from the Martha Ann Keels, DDS, PhD; Division Head of
Duke Pediatric Dentistry, Duke Children's Hospital
31
Injury to the gums.

Chipped (fractured) teeth
Interference with normal oral function.
Allergic reaction/hypersensitivity to
metal (eg, nickel).
Interference with oral health evaluation.
Aspiration or ingestion possible if
jewelry becomes loose.
Grills
No studies show that grills are harmful
to the mouth. However, there is at least
one case report of a grill accelerating
the caries process in an adolescent.
Grill wearers should be counseled to:
Used with permission from the American Academy of Pediatric Dentistry (AAPD);
Reproduced with AAPD permission
32
Remove the grill when eating.

Limit the amount of time the grill is worn.
Brush and floss carefully.
Watch for symptoms of allergy to the grill's metal.
Question #1
Which of the following is a risk factor for caries in
adolescents?
A. Poor oral hygiene
B. Inadequate access to topical fluoride

C. Previous caries experience
D. Frequent access to sugars
E. All of the above
33
Answer
Which of the following is a risk factor for caries in
adolescents?
A. Poor oral hygiene
B. Inadequate access to topical fluoride
C. Previous caries experience
D. Frequent access to sugars
E. All of the above
34
Question #2
Which of the following is not a sign or symptom of
periodontal disease?
A. Loose teeth
B. Leukoplakia
C. Halitosis
D. Swollen gums
E. Gums that bleed easily
35
Answer
Which of the following is not a sign or symptom of
periodontal disease?
A. Loose teeth
B. Leukoplakia
C. Halitosis
D. Swollen gums
E. Gums that bleed easily
36
Question #3
Which of the following behaviors can affect salivary flow and
change the acidity of the mouth?
A. Oral piercings
B. Using tobacco
C. Using illicit drugs
D. Wearing a grill
E. All of the above
37
Answer
Which of the following behaviors can affect salivary flow and
change the acidity of the mouth?
A. Oral piercings
B. Using tobacco
C. Using illicit drugs
D. Wearing a grill
E. All of the above
38
Question #4
True or False? Approximately 30% of high school students
are smokers.
A. True
B. False
39
Answer
True or False? Approximately 30% of high school students
are smokers.
A. True
B. False
40
Question #5
Which of the following can cause gingivitis?
A. Pregnancy
B. Smoking
C. Certain medications
D. All of the above
E. None of the above
41
Question #5
Which of the following can cause gingivitis?
A. Pregnancy
B. Smoking
C. Certain medications
D. All of the above
E. None of the above
42
References
1. American Academy of Pediatric Dentistry. Guideline on Adolescent Oral Health Care. AAPD
Reference Manual. 2005-2006. P. 72-79.
2. American Academy of Pediatric Dentistry. Policy on Intraoral/Perioral Piercing and Oral
Jewelry/Accessories. Revised 2011. Reference Manual. 35 (6): 65-66. Accessed December 20, 2013.
3. American Academy of Pediatric Dentistry. Periodontal Diseases of Children and Adolescents.
Reference Manual. 2004; 35(6): 338-345.
3. American Dental Association. Grills, grillz, and fronts. JADA. 2006; 137:1192.
4. American Dental Association. Oral piercing and health. JADA. 2001; 132:127.
5. Borgnakke W, Ylostalo P, Taylor G. et al. Effect of periodontal disease on diabetes: Systematic
review of epidemiologic observational evidence. J Periodontol. 2013; 84(4 Suppl): 135152.
6. Brown LJ, Brunelle JA, Kingman A. Periodontal status in the United States, 1988-1991:
prevalence, extent and demographic variations [special issue]. J Dent Res. 1996; 75:672-83
7. Campbell A, Moore A, Williams E, Stephens J, Tatakis DN. Tongue piercing: impact of time and
barbell stem length on lingual gingival recession and tooth chipping. J Periodontology. 2002;
73(3):289-297.
43
References
8. Casamassimo P. Bright futures in practice: Oral health. Arlington, VA. National Center for
Education in Maternal and Child Health. 1996.
9. CDC. Youth Risk Behavior Surveillance, United States 2009, Surveillance Summaries, June 4.
MMWR 2010; 59(No. SS-5).
10. Dietrich T, Sharma, P, Walter, C et al. The epidemiological evidence behind the association
between periodontitis and incident atherosclerotic cardiovascular disease. J Periodontol. 2013; 84
(Suppl 4), 7084.
11. Hollowell WH, Childers NK. A New Threat to Adolescent Oral Health: The Grill. Pediatr Dent.
2007; 29(4): 320-2.
12. Howe AM. Methamphetamine and childhood and adolescent caries. Aust Dent J. 1995;
40(5):340.
13. Ide M, Papapanou PN. Epidemiology of association between maternal periodontal disease and
adverse pregnancy outcomes - systematic review. J Periodontol. 2013. 84(4 Suppl): 181194.
14. Kapferer I, Beier US, Persson RG. Tongue Piercing: The Effect of Material on Microbiological
Findings. Journal of Adolescent Health. 2011; 49(1):76-83.
References, continued
15. Linden GJ, Lyons A, Scannapieco FA. Periodontal systemic associations: review of the evidence.
J Periodontol. 2013; 84(Suppl 4):S8-S19.
16. Ludwig DS, Peterson KE, Gormaker SL. Relation between consumption of sugar-sweetened
drinks and childhood obesity: A prospective, observational analysis. Lancet. 2001; 357(9255):
505-8.
17. Oh TJ, Eber R, Wang HL. Periodontal diseases in the child and adolescent. J Clin Periodontol.
2002; 29(5):400-10.
18. The Society of Teachers of Family Medicine. Smiles for Life: A national oral health curriculum.
Available online at: wwwsmilesforlifeoralhealth.org. Accessed May 25, 2013.
19. US Department of Health and Human Services. Oral health in America: A Report of the Surgeon
General. Rockville MD: US Department of Health and Human Services, National Institute of
Dental and Craniofacial Research, National Institutes of Health; 2000. Available online at
www.nidcr.nih.gov/DataStatistics/SurgeonGeneral. Accessed January 18, 2013.
20. Wyshak G. Teenaged girls, carbonated beverage consumption, and bone fractures. Arch
Pediatr Adolesc Med. 2000; 154(6):610-3.
45

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Protecting All Childrens Teeth

Because adolescents often have an increased focus on personal

List common risk factors for dental caries during adolescence.

Dental Caries, continued

Inadequate access to fluoride (especially topical fluoride)

Sweetened sugar beverages including soda, sports drinks and juice

Sugared beverage consumption is also a risk for obesity and osteoporosis

Sour candy and sticky snacks

Previous caries experience

Dental Caries, continued

Special health care needs

Infrequent professional dental care

Risk factors that may first be noted in the adolescent, include

Encourage fluoridated water intake.

Recommend fluoride supplementation for high risk teens not

Encourage fluoridated toothpaste use twice a day.

Encourage daily flossing.

Anticipatory Guidance, continued

Gingivitis is usually the result of suboptimal oral hygiene, both

The infection and inflammation spread from the gingiva to the

Signs and Symptoms of Periodontal

Gums that are swollen, bright red,

Antonio Moretti, DDS, MS Associate Professor, Department of

Localized Aggressive Periodontitis

Usually begins at onset of puberty

Clinical and radiographic exam by a dental team is very important

Localized Aggressive Periodontitis

Intra-oral condition is not necessarily linked to any systemic

Localized Aggressive Periodontitis

Arrows indicate sites with significant alveolar bone loss

Photos courtesy of:

Risk Factors for Periodontal Disease

Can be triggered by abrasions from oral piercings

Tobacco or marijuana use

Periodontal Link to Systemic Disease

Association with multiple other systemic diseases (cancer, arthritis,

Risk Factors for Oral Trauma

Compromised protective reflexes or poor coordination (children

Lack of use of protective face and mouth gear for athletes

Substance abuse (by the adolescent or within the family)

Child abuse or neglect

Malocclusion with protruding front teeth

26% of high school students report some tobacco use (cigarettes,

19.5% of high school students were current cigarette smokers.

14% of high school students reported cigar use.

8.9% of all high school students used smokeless tobacco.

Oral Effects of Tobacco

Tooth stains and discoloration

Encouraging patients to quit smoking or using chewing tobacco can

Illicit drug use can have negative effects on oral health by

and young adults.

Used with permission from the American Dental Association

Meth Mouth, continued

If meth mouth is discovered:

Gingivitis and periodontal disease

Signs and Symptoms of Oral Cancer

Oral Piercings and Grills

The American Dental Association and the American Academy

Oral piercing is a route of entry of bacteria into the bloodstream

Prolonged bleeding and possible nerve damage

Injury to the gums.

Remove the grill when eating.

B. Inadequate access to topical fluoride