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Child and Adolescent Health: Implications for Oral Health ... - Waterpik

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<strong>Child</strong> & <strong>Adolescent</strong> <strong>Health</strong>:<br />

<strong>Implications</strong> <strong>for</strong><br />

<strong>Oral</strong> <strong>Health</strong> Care Practitioners<br />

Course #12-22


Disclosure Statement:<br />

• The content <strong>for</strong> this self-study course was developed <strong>and</strong><br />

written by Carol A. Jahn, RDH, MS, a Water Pik, Inc. employee.<br />

• This course was designed, developed, <strong>and</strong> produced by<br />

Water Pik, Inc.<br />

• Water Pik, Inc. manufactures <strong>and</strong> distributes products<br />

addressed in this course.<br />

Course Objective:<br />

To provide the dental team with the research <strong>and</strong> in<strong>for</strong>mation<br />

needed to build a foundation <strong>for</strong> children’s <strong>and</strong> adolescents’<br />

optimal oral <strong>and</strong> general health now <strong>and</strong> throughout their lives.<br />

Learning Outcomes:<br />

• Identify the chronic diseases <strong>and</strong> conditions affecting<br />

children today.<br />

• Underst<strong>and</strong> the impact of active <strong>and</strong> second-h<strong>and</strong> smoke on<br />

general <strong>and</strong> oral health.<br />

• List the effects of diabetes <strong>and</strong> obesity on general <strong>and</strong><br />

oral health.<br />

• Evaluate the measures available <strong>for</strong> caries <strong>and</strong> gingivitis<br />

management <strong>and</strong> recommend products <strong>and</strong> regimens<br />

appropriate to address those needs.<br />

INTRODUCTION<br />

<strong>Child</strong>hood has always been a challenging time in regard to<br />

health. As recently as fifty years ago, children were susceptible<br />

to debilitating <strong>and</strong> sometimes life-threatening illnesses such<br />

as poliomyelitis, measles, mumps, <strong>and</strong> chicken pox. In the last<br />

thirty years, increased medical advances have helped arrest <strong>and</strong><br />

restrict outbreaks of many common childhood diseases. These<br />

improvements have set the stage <strong>for</strong> today’s children to live long<br />

<strong>and</strong> healthy lives. At no previous time in history has such an<br />

opportunity existed <strong>and</strong> been in such jeopardy.<br />

Rather than bacteria or viruses, health threats to the youth of<br />

today are more likely to come from lifestyle. The increasing rate<br />

of obesity fueled by poor eating habits <strong>and</strong> physical inactivity is<br />

creating a generation of youth at serious risk <strong>for</strong> developing earlyonset<br />

chronic health conditions. 1,2 Because of this, many experts<br />

believe children today will have a life expectancy shorter than<br />

their parents. 1,2,3<br />

THE OBESITY FACTOR<br />

One in three US children <strong>and</strong> adolescents are overweight or<br />

obese, which is triple the rate from 1963. These overweight or<br />

obese children have a 70%–80% percent chance of remaining<br />

overweight or obese throughout their lifetimes. 4 Obesity is now<br />

the number one health concern among parents, topping drug<br />

abuse <strong>and</strong> smoking. 1 It is the second leading cause of preventable<br />

death. Obesity impacts every organ of the body <strong>and</strong> is associated<br />

with more chronic disease than smoking or excessive drinking. 1 A<br />

New Engl<strong>and</strong> Journal of Medicine study found obesity threatens<br />

to diminish the overall health <strong>and</strong> decrease the life expectancy of<br />

current <strong>and</strong> future generations. 3 It is a major contributing factor<br />

in the development of chronic diseases such as type 2 diabetes,<br />

cardiovascular disease, liver disease, <strong>and</strong> asthma. It contributes to<br />

low self-esteem, social stigmatization, <strong>and</strong> depression. 2<br />

“Looking out the window, we see<br />

a threatening storm – obesity –<br />

that will, if unchecked, have a<br />

negative effect on life expectancy.” 3<br />

Obese children are likely to become obese adults. Eighty percent<br />

of children who were obese between the ages of 10 <strong>and</strong> 15 years<br />

became obese adults 25 years later. If weight problems begin<br />

be<strong>for</strong>e the age of eight, obesity in adulthood is likely to be more<br />

severe. 2 <strong>Child</strong>hood overweight issues <strong>and</strong> obesity are defined<br />

through the body mass index (BMI), which takes age, gender, <strong>and</strong><br />

growth into consideration (Table 1). 2<br />

Table 1 2 : BMI-<strong>for</strong>-age<br />

Underweight<br />

Normal<br />

Overweight<br />

Obese<br />

< 5 th percentile<br />

5 th percentile to < 85 th percentile<br />

85 th percentile to < 95 th percentile<br />

> 95 th percentile<br />

Becoming overweight or obese is the result of taking in more<br />

calories than are used, which often means eating too much <strong>and</strong><br />

not getting enough physical activity. Genetics can also influence<br />

susceptibility. However, the prevailing thought is that genetic<br />

factors have remained stable with lifestyle factors more strongly<br />

at play. In today’s society, portions are larger, sugar intake has<br />

increased, <strong>and</strong> children are less physically active. 1,2<br />

As portions increase, people eat more—up to 30% more in some<br />

cases. <strong>Adolescent</strong>s today eat 8% more than they did 30 years ago.<br />

Eating an extra 110–165 calories per day can result in gaining 10 or<br />

more pounds in a year. Consumption of packaged, convenience,<br />

<strong>and</strong> fast food has increased. 1,4 There is greater consumption of<br />

sugar-sweetened beverages including fruit drinks, juices, <strong>and</strong><br />

sports drinks. 1,4 Fewer than one in ten high school students get the<br />

recommended amounts of fruits <strong>and</strong> vegetables daily. French fries<br />

are the most common source of vegetables in children, <strong>and</strong> juice<br />

constitutes 40% of children’s fruit intake. <strong>Child</strong>ren consume less<br />

dairy products than in the past <strong>and</strong> tend to drink more whole <strong>and</strong><br />

chocolate milk than 1% or skim. 1 Daily snacking is on the increase;<br />

children consume on average 27% of all calories through snacks. 5<br />

Between 1970 <strong>and</strong> 2005, the average intake of added sugar<br />

increased nineteen percent (22.2 teaspoons per day). Added sugar<br />

2


is defined as sugars <strong>and</strong> syrups (<strong>for</strong> example, high-fructose corn<br />

syrup) that are added to foods during processing or preparation.<br />

Added sugar also includes sugars <strong>and</strong> syrups added at the table.<br />

The highest added-sugar-intake is in 14–19 year-old boys at 34.3<br />

teaspoons (549 calories) per day. Soft drinks <strong>and</strong> sugar-sweetened<br />

beverages are the primary source of added sugar in the diet. When<br />

sugar-sweetened beverages are added to a meal, the amount of<br />

food eaten increases by 10%–26%. It is believed that fluids may<br />

contribute more to weight gain than solid foods because fluids are<br />

less likely to satiate hunger. 6<br />

It is believed that fluids may contribute more<br />

to weight gain than solid foods because<br />

Table* 2 8<br />

fluids are less likely to satiate hunger. 6<br />

<strong>Child</strong>ren need 60 minutes of moderate to vigorous activity every<br />

day. As children age, physical activity levels decrease. 1 <strong>Child</strong>ren<br />

spend less time per<strong>for</strong>ming physical activities while at school;<br />

many schools do not require daily physical education even in<br />

elementary school. 1 Instead, children spend more time with media.<br />

A Kaiser Family Foundation report found that youth spend 7<br />

hours <strong>and</strong> 38 minutes per day consuming media. Many use more<br />

than one medium at a time (listening to music while using the<br />

computer). More youth than ever own a cell phone, <strong>and</strong> they use it<br />

to do more than make calls. Twenty percent of media consumption<br />

occurs on mobile devices. Seventh to twelfth graders spend 1.5<br />

hours per day texting. However, television viewing still dominates<br />

consumption (4.29 hours per day), but it too occurs in new<br />

ways such as with mobile devices. 7 <strong>Child</strong>ren who watch a lot of<br />

television are exposed to food advertising. More than half of all ads<br />

targeted to children are <strong>for</strong> food. 1<br />

Diabetes <strong>and</strong> Prediabetes<br />

Every year, more than 15,000 people aged 20 <strong>and</strong> younger<br />

are diagnosed with type 1 diabetes. 8,9 Type 1 is most common<br />

in non-Hispanic whites <strong>and</strong> has been increasing at a rate of<br />

about 3% annually. The reason <strong>for</strong> the rise in type 1 diabetes<br />

is underdetermined, although living in the contemporary<br />

environment with less exposure to viruses <strong>and</strong> bacteria that help<br />

the immune system mature is one theory. 10<br />

Type 2 diabetes in youth is rare but is on the rise due to increasing<br />

rates of childhood obesity. 10 It is considered the “first consequence”<br />

of the obesity epidemic. 8 When type 2 diabetes occurs, it is more<br />

commonly seen after age 10 in minority populations. Among<br />

non-Hispanic black <strong>and</strong> Hispanic youth between the ages of<br />

10 <strong>and</strong> 19, the rates of new cases of type 1 <strong>and</strong> type 2 diabetes<br />

are now similar. 8 Prediabetes, a condition in which fasting blood<br />

glucose levels are higher than normal (100–125 mg/dL) but not<br />

high enough to be considered diabetes is a strong risk factor <strong>for</strong><br />

type 2 diabetes. 9 Approximately one in six overweight adolescents<br />

are believed to have this condition. 10<br />

Type 2 diabetes usually develops slowly in children <strong>and</strong> may go<br />

undiagnosed <strong>for</strong> an extended period of time. Some children have<br />

symptoms similar to those found with type 1 such as extreme<br />

thirst or frequent urination. Others may have frequent infections<br />

including bladder or yeast infections. Many have no symptoms at<br />

all. Elevated blood pressure <strong>and</strong> cholesterol may be present. 8 One<br />

physical sign that may be present in as many as 90% of children<br />

with type 2 diabetes is acanthosis nigrans. 10 This is a skin disorder<br />

characterized by velvety, dark-pigmented patches often occurring<br />

around the neck or armpits. 8,11 Table 2 highlights the current<br />

diabetes risk factors <strong>and</strong> testing criteria to help identify type 2<br />

diabetes in children. 8<br />

Overweight: BMI > 85 th percentile <strong>for</strong> age <strong>and</strong> gender; weight<br />

<strong>for</strong> height > 85 th percentile or weight > 120% of ideal <strong>for</strong> height<br />

PLUS any of the following two risk factors:<br />

• Family history of type 2 diabetes in a 1st or 2nd degree relative<br />

• Race or ethnicity of American Indian, African American,<br />

Hispanic or Latino, Asian American, or Pacific Isl<strong>and</strong>er<br />

• Signs of insulin resistance such as acanthosis nigrans,<br />

hypertension, dyslipidemia, polycystic ovarian, syndrome,<br />

or small-<strong>for</strong>-gestational-age birth weight<br />

• Maternal history <strong>for</strong> gestational diabetes during child’s gestation<br />

*Adapted from National Diabetes Education Program<br />

Cardiovascular Disease<br />

A 2012 report in the journal Pediatrics found that 49% of<br />

overweight <strong>and</strong> 61% of obese adolescents had one or more risk<br />

factors <strong>for</strong> CVD compared with 37% of normal-weight children.<br />

The factors evaluated include prehypertension or hypertension,<br />

borderline high or high LDL, low HDL, <strong>and</strong> prediabetes or<br />

diabetes. The investigators found that a significant portion of<br />

those overweight or obese had two CVD risk factors <strong>and</strong> obesity<br />

increased the likelihood of having three or more risk factors. 12<br />

This study complements findings from a 2005 study that found<br />

adolescents with a high BMI <strong>and</strong> insulin resistance were more<br />

likely to have significantly higher cholesterol, triglycerides, <strong>and</strong><br />

systolic blood pressure compared with teens with a normal fasting<br />

glucose. 11 In 2010, a study of children between the ages 6 <strong>and</strong> 19<br />

years with obesity <strong>and</strong> atherosclerotic risk factors found that 75%<br />

had carotid artery intima media thickness comparable to a 45<br />

A study of children ages 6 <strong>and</strong> 19 years with obesity<br />

<strong>and</strong> atherosclerotic risk factors found that<br />

75% had carotid artery<br />

intima media thickness<br />

comparable to a 45 year old. 13<br />

year-old. 13 3


It is predicted that obese adolescents with cardiovascular risk<br />

factors will become young <strong>and</strong> middle-aged adults with earlyonset<br />

coronary heart disease (CHD). By 2035, CHD is predicted<br />

to increase by 5%–16% with 100,000 excess cases attributable to<br />

obesity. This group will experience higher rates of hospitalizations,<br />

procedures, disability, long-term use of medications, <strong>and</strong><br />

premature death at working age. 14<br />

Liver Disease<br />

Obesity is a risk factor <strong>for</strong> a disorder called non-alcoholic fatty liver<br />

disease (NAFLD). In NAFLD, there is an accumulation of excess fat<br />

in the liver of people who drink little or no alcohol. It affects about<br />

20% of adults <strong>and</strong> 5% of children. It is estimated that it may occur<br />

in half of all obese children. 15<br />

Many people with NAFLD have no symptoms, although children<br />

with it may experience upper-right abdominal pain <strong>and</strong> fatigue. A<br />

physical exam may detect a slightly enlarged liver <strong>and</strong> acanthosis<br />

nigrans. Other findings may include insulin resistance, high blood<br />

pressure, <strong>and</strong> elevated cholesterol <strong>and</strong>/or triglycerides. It is<br />

generally diagnosed through elevated liver enzymes shown during<br />

routine blood testing. It is confirmed via a liver ultrasound. Some<br />

now recommend that all obese children be screened <strong>for</strong> NAFLD. 15<br />

Social Stigmatization<br />

Even though a greater number of children than ever are<br />

overweight or obese, social stigmatization still exists. Overweight<br />

children may experience teasing about their weight from both<br />

family members <strong>and</strong> peers. A recent study of sixth-graders<br />

found that 40% of those overweight or obese had been teased<br />

by peers <strong>and</strong> nearly an equal number, 36%, had been teased by<br />

family members. 20 Other research has shown that obese children<br />

experience more social isolation than their healthy-weight peers<br />

by having fewer friends <strong>and</strong> being on the periphery of social<br />

networks. 21<br />

Bullying is another problem <strong>for</strong> overweight <strong>and</strong> obese adolescents.<br />

A school-based study of adolescents in Connecticut found<br />

that most students had observed verbal threats <strong>and</strong> physical<br />

harassment toward overweight or obese students. The data<br />

showed that 84% of overweight students were teased in a mean<br />

way while per<strong>for</strong>ming physical activities. For overweight or obese<br />

students, being ignored, avoided, or excluded from social activities<br />

was common, as was being subjects of negative rumors <strong>and</strong><br />

targets <strong>for</strong> teasing in the cafeteria. 22<br />

In most people NAFLD causes no long-term problems; however,<br />

in about 25% of cases the liver may get worse with time <strong>and</strong> have<br />

scarring, leading to cirrhosis. This advanced state has become<br />

a more common reason <strong>for</strong> liver transplant in the United States.<br />

There are no medical treatments to reverse this condition. Weight<br />

loss has been associated with regression of liver fat. There<strong>for</strong>e,<br />

most physicians recommend weight loss along with increased<br />

physical activity <strong>and</strong> a balanced diet. 15<br />

Asthma<br />

Asthma is the most common chronic disorder of children <strong>and</strong><br />

currently affects about 7.1 million children under the age of 18. It<br />

is the third leading cause of hospitalization in children under the<br />

age of 15 <strong>and</strong> is a leading cause of emergency room visits. It is a<br />

major factor in school absenteeism, resulting in 14.4 million lost<br />

school days per year. 16 What produces the onset of asthma is not<br />

well known, although it is believed to be a combination of both<br />

environmental <strong>and</strong> genetic factors. Environmental factors can<br />

include cigarette smoke, allergies, infections, <strong>and</strong> obesity. 17,18,19<br />

Emerging research indicates that children with obesity are at a<br />

higher risk of developing asthma. 18 Obesity is associated with an<br />

increased risk of having worse asthma control <strong>and</strong> exacerbations. 19<br />

There are several theories on how obesity influences the onset<br />

of asthma. Some believe that it can lead to airflow reduction <strong>and</strong><br />

decrease in lung volume. Others feel the release of adipokines<br />

<strong>and</strong> inflammatory agents by adipose tissues increases lung<br />

inflammation. It is also possible that dietary factors <strong>and</strong> sedentary<br />

behavior may play a role. Daily physical activity <strong>and</strong> weight loss<br />

are encouraged <strong>for</strong> children with concurrent obesity <strong>and</strong> asthma. 18<br />

THE EFFECT OF<br />

RISKY BEHAVIORS<br />

Cigarette smoking <strong>and</strong> spit-tobacco use are habits that often start<br />

during high school. Nearly 90% of adult smokers report beginning<br />

the habit be<strong>for</strong>e age 18 <strong>and</strong> 99% be<strong>for</strong>e age 26. 23 <strong>Adolescent</strong>s who<br />

use spit tobacco are more likely to become cigarette smokers as<br />

adults. 24 Use of more than one tobacco product is common; half of<br />

all high-school, male tobacco users reported using more than one<br />

tobacco product. 23 Smoking among high-school students declined<br />

significantly between 1997 <strong>and</strong> 2003. Since that time, the rate<br />

has declined more slowly to 18.7% of high school seniors. 23 Nearly<br />

9% use spit tobacco. 24 Tobacco use may be associated with other<br />

health-risk behaviors such as the use of alcohol or drugs <strong>and</strong> highrisk<br />

sexual behavior. 23,24<br />

4


Nearly half (47.4%) of all high school students reported being<br />

sexually active in 2011. A significant number of them do not<br />

employ safe-sex practices, with slightly less than 60% reporting<br />

condom use. Of the nearly 19 million sexually-transmitted-disease<br />

(STD) cases reported yearly, almost half occur in 15 to 24-yearolds.<br />

25 One of the most common STD infections is the human<br />

papilloma virus (HPV). This virus is so common that it is estimated<br />

at least half of sexually active people are infected with it at some<br />

point in their lives. 26<br />

Tobacco Use<br />

Smoking is the leading cause of preventable <strong>and</strong> premature death<br />

in the United States. Young people who smoke have decreased<br />

lung function, impaired lung growth, <strong>and</strong> a greater risk of early<br />

abdominal aortic atherosclerosis. About half of those who continue<br />

to smoke though adulthood are likely to die about 13 years earlier<br />

than a nonsmoking peer, generally from heart attack, chronic lung<br />

diseases, or cancer. For every person who dies from tobacco use,<br />

another 20 suffer from a tobacco-related illness. 27<br />

About 22% of children under the age of 18 are exposed to<br />

secondary smoke in their homes. Exposure to secondary smoke<br />

slows lung growth in children <strong>and</strong> makes them more susceptible<br />

to sudden infant death syndrome, ear problems, lower respiratory<br />

illness, <strong>and</strong> more severe asthma. There are more than 50<br />

carcinogens in second-h<strong>and</strong> smoke. 28 Low levels of exposure to<br />

second-h<strong>and</strong> smoke can lead to immediate endothelial dysfunction<br />

<strong>and</strong> inflammation. 27<br />

Human Papilloma Virus (HPV)<br />

HPVs are a group of more than 150 related viruses. Most<br />

are benign. About <strong>for</strong>ty can be easily spread through sexual<br />

transmission. It is estimated that at any given point in time more<br />

than 43% of women have a genital HPV infection <strong>and</strong> fewer than<br />

3% have an oral HPV infection. These types of infections usually do<br />

not cause any symptoms <strong>and</strong> go away without treatment within<br />

one to two years. Some are more persistent <strong>and</strong> have been directly<br />

related to cervical cancer. HPV 16 <strong>and</strong> 18 are associated with 70%<br />

of cervical cancers. 29<br />

In 2006, a vaccine was developed to prevent HPV infection. It<br />

is protective against the high-risk HPVs 16 <strong>and</strong> 18. 29 Whether to<br />

vaccinate is a personal decision, yet at the present time this is the<br />

only medical means of prevention.<br />

ORAL HEALTH IMPLICATIONS<br />

Obesity, diabetes, tobacco, <strong>and</strong> HPV can have significant oral<br />

health effects. These can range from an increased susceptibility<br />

to periodontal disease to a higher risk <strong>for</strong> oral cancer. Increased<br />

sugar consumption <strong>and</strong> second-h<strong>and</strong> smoke may contribute to an<br />

increased risk <strong>for</strong> caries.<br />

Gingivitis <strong>and</strong> Periodontal Disease<br />

Obesity, 30 diabetes, 31 <strong>and</strong> smoking 32 have all been shown to be<br />

related to early periodontal disease in adolescents <strong>and</strong> young<br />

adults. A systematic review of the relationship between obesity<br />

<strong>and</strong> periodontal disease found that obesity in women, nonsmokers,<br />

<strong>and</strong> younger individuals was associated with an increased risk<br />

of periodontal disease. These findings led the investigators to<br />

conclude that the prevalence of periodontal disease is likely to<br />

be higher in obese individuals. 30<br />

It is well established in adults that diabetes can increase the<br />

prevalence <strong>and</strong> severity of periodontal disease. <strong>Child</strong>ren with<br />

diabetes have been shown to have a greater prevalence of<br />

gingivitis compared to children without diabetes even with similar<br />

plaque levels. Poor metabolic control can also increase the severity<br />

of inflammation in children. 33 Periodontal disease has been shown<br />

to occur earlier in life <strong>for</strong> children with diabetes <strong>and</strong> become more<br />

pronounced into adolescence. <strong>Child</strong>ren between the ages of 6 <strong>and</strong><br />

18 years with diabetes were more likely to have at least one tooth<br />

with attachment loss greater than 2 mm. As the children got older<br />

more teeth were affected. 31<br />

<strong>Child</strong>ren with diabetes have been shown<br />

to have a greater prevalence of gingivitis<br />

compared to children without<br />

diabetes with similar plaque levels. 33<br />

Smoking is the most significant risk factor <strong>for</strong> periodontal disease<br />

in adults. Young adult smokers have been shown to have a higher<br />

prevalence <strong>and</strong> severity of periodontal disease compared to<br />

nonsmokers. 34 Teen smokers (15–16 year-olds) have been shown to<br />

have more visible plaque, periodontal pockets > 4 mm, <strong>and</strong> root<br />

surface calculus than their nonsmoking counterparts. 33 In addition<br />

to tobacco, regular exposure to cannabis smoking has been shown<br />

to increase the risk of periodontal attachment loss by age 32. 35<br />

Dental Caries<br />

Dental caries is the most prevalent chronic disease of children. 36<br />

Over 19% of children between the ages of 2 <strong>and</strong> 19 have untreated<br />

caries. While this rate is significantly less than the rate of 30 years<br />

ago (25%), it remains highest in black <strong>and</strong> Hispanic youths ranging<br />

from a little over 24% in black children ages 2–5 to over 30% in<br />

Hispanic children ages 6–19. 37 Caries is a multifactorial disease<br />

influenced by many things including diet, fluoride exposure, home<br />

care, <strong>and</strong> socioeconomic status. 38 A two-year study of children<br />

from low-income families ages 3–5 at the study onset found that<br />

those who consumed more soft drinks relative to milk <strong>and</strong> 100%<br />

fruit juice were at a greater risk of developing caries as they aged. 39<br />

5


A recent case-control study on the relationship between obesity<br />

<strong>and</strong> caries found that obese adolescents were more likely to have<br />

reduced salivary flow <strong>and</strong> a higher rate of decay. The subjects<br />

also had more gingival inflammation than their healthy-weight<br />

peers. 40 Lalla et al. found that children with diabetes the majority,<br />

94%, with type 1, were not more likely to have decay than other<br />

children. 31 Interestingly, children exposed to second-h<strong>and</strong> smoke<br />

have been shown to be at increased risk <strong>for</strong> decay in primary<br />

teeth. As the rate of exposure increased so did the rate of caries.<br />

While the cause <strong>for</strong> this is poorly understood, nicotine has been<br />

shown to promote the growth of Strep. mutans. Additionally,<br />

second-h<strong>and</strong> smoke has immunosuppressive properties that have<br />

been shown to put children at greater risk <strong>for</strong> other infections of<br />

the head <strong>and</strong> neck such as otitis media. Another possibility is that<br />

second-h<strong>and</strong> smoke interferes with the protective properties<br />

of saliva. 41<br />

<strong>Oral</strong> Cancer<br />

Smoking <strong>and</strong> spit-tobacco use are two of the strongest risk<br />

factors <strong>for</strong> oral cancer. Most people who develop oral cancer<br />

use tobacco products. Seven in ten people with oral cancer<br />

are heavy drinkers. Heavy drinking <strong>and</strong> smoking is believed to<br />

result in a 100 times greater risk of oral cancer. Abnormal tissue<br />

like leukoplakia <strong>and</strong> erythroplakia are almost always caused by<br />

smoking or spit-tobacco use. They may range from the harmless<br />

to the cancerous. Additional tests or a biopsy is the only way to<br />

confirm. Approximately one in five leukoplakias is cancerous or<br />

precancerous. Having an erythroplakias is less common than a<br />

leukoplakia but is more serious <strong>and</strong> more likely to be cancerous or<br />

precancerous. 42<br />

Recently, HPV has been shown to be a risk factor <strong>for</strong> oral cancer.<br />

New data indicate that HPV DNA, a sign of HPV infection can be<br />

found in about two out of three cases of oral cancers. HPV-related<br />

cancer is more likely to be found in the oropharynx, especially the<br />

tonsils, than the oral cavity. People who develop oral cancer due to<br />

an HPV infection are less likely to be heavy drinkers or smokers. 42<br />

A 2007 study found that infection with HPV 16 resulted in a 14<br />

times greater risk of oral cancer <strong>and</strong> that the exposure to HPV<br />

can precede the appearance of the cancer by 10 years or more. 43<br />

HPV-related oral cancer seems to have a better outcome than that<br />

caused by tobacco or alcohol. 42<br />

ORAL HEALTH INTERVENTIONS<br />

Preventive measures <strong>for</strong> caries <strong>and</strong> gingivitis may include both<br />

professional <strong>and</strong> at-home strategies. Fluoride <strong>and</strong> sealants<br />

continue to be the foundation <strong>for</strong> preventing decay, but other<br />

complementary options such as xylitol-based products now<br />

also play a role. Daily self-care is critical in preventing gingivitis<br />

<strong>and</strong> new research indicates that there are easier, more effective<br />

alternatives to string floss.<br />

Strategies <strong>for</strong> Caries Prevention<br />

In the past, it was assumed that all individuals were at equal risk <strong>for</strong><br />

caries. All patients generally received the same advice, brush, floss,<br />

<strong>and</strong> limit sugary foods, <strong>and</strong> the same measures, topical fluoride<br />

twice a year <strong>and</strong> sealant placement. Today, evidence indicates that<br />

due to the multifactorial nature of caries, risk varies from person<br />

to person <strong>and</strong> may change <strong>for</strong> a particular person over the course<br />

of time. 38 The new focus is on assessing caries risk <strong>and</strong> providing<br />

intervention <strong>and</strong> care based on risk—often called CAMBRA—Caries<br />

Management By Risk Assessment. 44<br />

Fluorides<br />

The first line of defense in reducing caries risk is adequate<br />

exposure to fluoride—ideally, small amounts on a daily basis. Some<br />

believe that regular fluoride intake has helped modify the caries<br />

potential of increased sugar consumption 38 as well as the cariesreduction<br />

impact of daily flossing. 45<br />

Professionally applied fluorides are one strategy that may be<br />

used to decrease the prevalence of caries. Conclusions from the<br />

American Dental Association (ADA) panel on the professional<br />

application of topical fluoride confirmed that fluoride gel <strong>and</strong> foam<br />

applied <strong>for</strong> four minutes every six months are effective means <strong>for</strong><br />

preventing decay in specific age groups. The panel also recognized<br />

fluoride varnish (Figure 1) applied every six months was effective<br />

in preventing caries in both primary <strong>and</strong> permanent dentition<br />

including in high-risk populations. Importantly, it was shown that<br />

fluoride varnish takes less time, creates less patient discom<strong>for</strong>t, <strong>and</strong><br />

achieves greater patient acceptability than fluoride gel, especially<br />

with preschool children. 46<br />

New data indicate that HPV DNA,<br />

a sign of HPV infection can be found in about<br />

two to three cases of oral cancers. 42<br />

…fluoride varnishes take less time,<br />

create less patient discom<strong>for</strong>t, <strong>and</strong><br />

achieve greater patient acceptability<br />

than fluoride gel, especially<br />

with preschool children. 46<br />

6


Power Toothbrushes<br />

Toothbrushing is the most common tool<br />

that people use <strong>for</strong> plaque removal. Yet<br />

effectiveness can vary among individuals<br />

especially children. A power brush may be an<br />

excellent choice <strong>for</strong> children <strong>and</strong> adolescents,<br />

especially those who have difficulty brushing<br />

or are in orthodontic therapy.<br />

Figure 1: <strong>Waterpik</strong> ® UltraThin 5% Sodium Fluoride Varnish<br />

Sealants<br />

A report from the ADA on evidence-based recommendations<br />

<strong>for</strong> the use of pit <strong>and</strong> fissure sealants found that the reduction<br />

in caries from sealant placement ranges from 86% at one year<br />

to 58.6% at four years. They also found consistent evidence that<br />

sealant placement is associated with a reduction in the need <strong>for</strong><br />

restorative services. Sealants can be placed to prevent caries <strong>and</strong><br />

over early noncavitated lesions to arrest progression. 47 No evidence<br />

was found to support the contention that placing a sealant over<br />

existing caries would increase the bacteria <strong>and</strong> caries potential<br />

of the lesion. Instead, sealants were associated with a 100-fold<br />

reduction in total viable bacteria counts. 47,48<br />

Sonic toothbrushes are a very popular type of<br />

power toothbrush (Figure 2). One study found<br />

that the <strong>Waterpik</strong> ® Sensonic ® Professional<br />

Plus Toothbrush (Water Pik, Inc., Fort Collins,<br />

CO) was significantly more effective than the<br />

Sonicare ® FlexCare, (Philips <strong>Oral</strong> <strong>Health</strong>care,<br />

Snolquamie, WA) in removing plaque (29%)<br />

<strong>and</strong> reducing bleeding (26%) <strong>and</strong> gingivitis<br />

(20%) 50 (Figures 3, 4, <strong>and</strong> 5).<br />

Figure 2: <strong>Waterpik</strong> ® Sensonic ®<br />

Professional Plus Toothbrush—<br />

Model SR-3000W<br />

Xylitol<br />

Xylitol is a naturally occurring carbohydrate sweetener that is not<br />

fermentable by cariogenic bacteria such as Streptococcus mutans.<br />

It has a taste similar to sucrose. Research has indicated that<br />

the regular use of xylitol-containing products may significantly<br />

reduce the incidence of caries in both adults <strong>and</strong> children. The<br />

effectiveness of xylitol is dependent upon dosage <strong>and</strong> frequency.<br />

It is recommended to use 6–7 grams daily in 3–5 separate<br />

episodes <strong>for</strong> periods of several weeks to a year. Xylitol is found<br />

most frequently in chewing gum <strong>and</strong> mints. Recently, studies have<br />

shown another sugar alcohol, erythritol, to have anticariogenic<br />

activity. More long-term clinical trials are needed to confirm<br />

these results. 49<br />

Figure 3: <strong>Waterpik</strong> ® Sensonic ® versus<br />

Sonicare ® FlexCare <strong>and</strong> a manual<br />

toothbrush; plaque reductions<br />

Strategies <strong>for</strong> Gingivitis Prevention<br />

Plaque-induced gingivitis is common in children <strong>and</strong> adolescents.<br />

Dexterity is sometimes a problem with younger children, while<br />

many adolescents have challenges due to malocclusion or<br />

orthodontic appliances. Compliance may be a factor at any age.<br />

Helping children <strong>and</strong> adolescents improve <strong>and</strong> maintain good<br />

oral health through daily self-care can be challenging. The good<br />

news <strong>for</strong> dental professionals is that there is a wide variety of<br />

colorful, high-technology, easy-to-find power products <strong>for</strong> self-care<br />

available that are likely to appeal to this age group.<br />

Figure 4: <strong>Waterpik</strong> ® Sensonic ® versus<br />

Sonicare ® FlexCare <strong>and</strong> a manual<br />

toothbrush; bleeding reductions<br />

Figure 5: <strong>Waterpik</strong> ® Sensonic ® versus<br />

Sonicare ® FlexCare <strong>and</strong> a manual<br />

toothbrush; gingivitis reductions<br />

7


Interdental Cleaning<br />

Most children need some type of<br />

interdental cleaning, especially as<br />

permanent teeth erupt <strong>and</strong> the teeth<br />

become closer together. Dental floss<br />

has long been the primary self-care<br />

recommendation made by most dental<br />

professionals. However, dental floss<br />

may not be the best product choice <strong>for</strong><br />

younger individuals because the dexterity<br />

required to use the product adequately<br />

may not be present.<br />

The <strong>Waterpik</strong> ® Water Flosser is clinically<br />

proven to be an easier, more effective<br />

alternative to string floss. Three studies<br />

with three different types of tips (Classic<br />

Jet Tip, Plaque Seeker ® Tip, Orthodontic<br />

Tip) (Figures 6, 7, <strong>and</strong> 8) have compared<br />

the Water Flosser to string floss. In<br />

each study, the Water Flosser provided<br />

superior results over string floss <strong>for</strong><br />

reducing gingival bleeding (Figures 9<br />

<strong>and</strong> 10) <strong>and</strong> similar or superior results<br />

in regard to plaque removal. 51,52,53 For<br />

children ages 6–11, the <strong>Waterpik</strong> ® Water<br />

Flosser For Kids (Figure 11) is designed<br />

to fit small h<strong>and</strong>s. <strong>Adolescent</strong>s <strong>and</strong> teens<br />

may prefer the <strong>Waterpik</strong> ® Ultra Water<br />

Flosser (Figure 12).<br />

Figure 6: Classic Jet Tip<br />

Figure 11: <strong>Waterpik</strong> ®<br />

Water Flosser For Kids,<br />

Model WP-260W<br />

Figure 12: <strong>Waterpik</strong> ®<br />

Ultra Water Flosser,<br />

Model WP-100W<br />

Figure 7: Plaque Seeker ® Tip<br />

Figure 13: <strong>Waterpik</strong> ®<br />

Complete Care,<br />

Figure 8: Orthodontic Tip<br />

Model WP-900W<br />

Figure 9: Reduction of<br />

Gingival Bleeding Compared<br />

to String Floss 51<br />

Using both a sonic toothbrush <strong>and</strong> a Water Flosser can provide<br />

additional benefits over using either a sonic toothbrush or manual<br />

toothbrush alone. A four-week study with 140 subjects found that<br />

individuals who used a combination device (<strong>Waterpik</strong> ® Complete<br />

Care, Figure 13) of a Water Flosser <strong>and</strong> <strong>Waterpik</strong> ® Sensonic ®<br />

Professional Plus Toothbrush had a 70% better reduction in bleeding<br />

Figure 10: Reduction<br />

<strong>and</strong> 52% better reduction in plaque removal compared with those<br />

of Gingival Bleeding<br />

who used the Sonicare ® FlexCare only. In comparison to a manual<br />

at 14 Days 52 toothbrush, the Complete Care regimen was 159% better at<br />

reducing bleeding <strong>and</strong> 134% better at plaque removal 50 (Figure 14).<br />

A study to investigate plaque biofilm removal with the Water Flosser<br />

was undertaken at the University of Southern Cali<strong>for</strong>nia Center <strong>for</strong><br />

Biofilms. The investigators evaluated the effect of a three-second<br />

pulsating (1,200 per minute) lavage at medium pressure on plaque<br />

biofilm using scanning electron microscopy (SEM). The results<br />

showed that the Water Flosser with the Classic Jet Tip removed<br />

8


A study of adolescents with fixed orthodontic appliances found<br />

that the use of the Water Flosser with the Orthodontic Tip <strong>and</strong><br />

plain water was three times as effective as string floss <strong>and</strong> five<br />

times as effective as brushing alone at removing plaque. The<br />

addition of the Water Flosser also provided a significantly better<br />

reduction in bleeding—84.5% from baseline. This was 26% better<br />

than the results achieved with dental floss 52 (Figure 17).<br />

Figure 14: <strong>Waterpik</strong> ® Complete Care versus<br />

Sonicare ® FlexCare <strong>and</strong> a manual toothbrush:<br />

bleeding reductions<br />

Figure 17: Reduction of Plaque with<br />

Water Flosser Versus String Floss 52<br />

Figure 15: Be<strong>for</strong>e treatment with the<br />

Water Flosser 54<br />

Figure 18: Reduction of Bleeding in<br />

Patients with Diabetes 55<br />

Figure 16: Tooth Surface after 3-Second<br />

Treatment with Water Flosser 54<br />

99.9% of plaque biofilm (Figures 15 <strong>and</strong> 16). The researchers<br />

concluded that the hydraulic <strong>for</strong>ces produced by the Water Flosser<br />

with 1,200 pulsations at medium pressure can significantly remove<br />

plaque biofilm from treated areas of tooth surfaces. 54<br />

Orthodontic Appliances<br />

Orthodontic appliances present special cleaning challenges. It can<br />

be difficult to manipulate a floss threader in <strong>and</strong> around braces.<br />

Yet, poor oral hygiene can lead to a less than desirable outcome<br />

that may include decay, white spot lesions, <strong>and</strong> gingivitis. The<br />

Water Flosser is an ideal choice <strong>for</strong> people with orthodontic<br />

appliances. It is easy to use <strong>and</strong> can reach hard-to-access areas<br />

often missed by toothbrushes <strong>and</strong> other interdental devices. It<br />

is gentle on swollen <strong>and</strong> tender tissue, effectively reducing the<br />

severity of those symptoms, often within two weeks. 52<br />

Diabetes<br />

<strong>Child</strong>ren with diabetes often have more gingival inflammation. One<br />

study looked at the effect of a Water Flosser on individuals with<br />

diabetes. The investigators found that the addition of the Water<br />

Flosser to routine oral hygiene was 44% more effective at reducing<br />

bleeding <strong>and</strong> 41% more effective at reducing gingivitis than routine<br />

oral hygiene 55 (Figure 18).<br />

CONCLUSION<br />

<strong>Child</strong>ren <strong>and</strong> adolescents are at risk <strong>for</strong> chronic diseases that can<br />

potentially threaten quality of life <strong>and</strong> longevity. Many of these<br />

conditions can impact oral health. In addition to traditional oral<br />

health advice, dental professionals may be called upon to play a<br />

role in helping today’s youth achieve a healthy lifestyle especially<br />

in regard to sugar consumption, diabetes, <strong>and</strong> the HPV infection.<br />

9


References<br />

1. American Heart Association. Underst<strong>and</strong>ing childhood obesity. 2011.<br />

Available at: http://www.heart.org/idc/groups/heart-public/@wcm/@fc/<br />

documents/downloadable/ucm_428180.pdf. Accessed June 28, 2012.<br />

2. Centers <strong>for</strong> Disease Control. <strong>Child</strong>hood overweight <strong>and</strong> obesity.<br />

Available at: http://www.cdc.gov/obesity/childhood/index.html.<br />

Accessed June 29, 2012.<br />

3. Olshansky SJ et al. A potential decline in life expectancy in the United<br />

States in the 21st Century. N Engl J Med 2005; 352:1138–1145.<br />

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Trust <strong>for</strong> America’s <strong>Health</strong> <strong>and</strong> the Robert Wood Johnson Foundation.<br />

July 2011. Available at: http://www.healthyamericans.org/report/88/<br />

5. Peirnas C, Popkin B. Trends in snacking among US children. <strong>Health</strong> Aff<br />

(Millwood). 2010; 29:398-404.<br />

6. Johnson RK et al. Dietary sugars intake <strong>and</strong> cardiovascular health. A<br />

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7. A Kaiser Family Foundation Study. Generation M2. Media in the lives of<br />

8-18 year olds. January 2010. Available at: http://www.kff.org/entmedia/<br />

upload/8010.pdf Accessed July 11, 2012.<br />

8. National Diabetes Education Program. Overview of diabetes in children<br />

<strong>and</strong> adolescents. June 2011. Available at: http://ndep.nih.gov//media/<br />

Youth_FactSheet.pdf. Accessed on July 11, 2012.<br />

9. National Diabetes Fact Sheet. United States, 2011. Department of <strong>Health</strong><br />

<strong>and</strong> Human Services. Centers <strong>for</strong> Disease Control <strong>and</strong> Prevention.<br />

Available at: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf.<br />

Accessed July 11, 2012.<br />

10. Diabetes rates increase significantly among American young. American<br />

Diabetes Association Annual Meeting, Philadelphia PA, June 9, 2012.<br />

11. Williams DE et al. Prevalence of impaired fasting glucose <strong>and</strong> its<br />

relationship with cardiovascular disease risk factors in US adolescents,<br />

1999-2000. Pediatrics 2005; 116(5):1122-1126.<br />

12. May AL et al. Prevalence of cardiovascular disease risk factors among<br />

US adolescents, 1999-2008. Pediatrics 2012; 129:1035–1041.<br />

13. Le J et al. “Vascular age” is advanced in children with atherosclerosispromoting<br />

risk factors. Circ Cardiovasc Imaging 2010; 3:8–14.<br />

14. Bibbins-Domingo K et al. <strong>Adolescent</strong> overweight <strong>and</strong> future adult<br />

coronary heart disease. N Engl J Med 2007; 357:2371–2379.<br />

15. Feldstein AE, Kay MH. Fatty liver disease. The American College of<br />

Gastroenterology. Available at http://www.acg.gi.org/patients/gihealth/<br />

fld.asp. Accessed July 19, 2012.<br />

16. American Lung Association. Asthma <strong>and</strong> children fact sheet. Available<br />

at: http://www.lungusa.org/lung-disease/asthma/resources/facts-<strong>and</strong>figures/asthma-children-fact-sheet.html.<br />

Accessed July 19, 2012.<br />

17. Mayo Clinic. Causes of asthma. Available at: http://www.mayoclinic.com/<br />

health/asthma/DS00021/DSECTION=causes. Accessed July 19, 2012.<br />

18. Lang JE. Obesity, nutrition, <strong>and</strong> asthma in children. Pediatr Allergy<br />

Immunol Pulmonol 2012; 25:64–75.<br />

19. Quinto KB et al. The association of obesity <strong>and</strong> asthma severity <strong>and</strong><br />

control in children. J Allergy Clin Immunol 2011; 128: 964–969.<br />

20. McCormack LA et al. Weight-related teasing in a racially diverse sample<br />

of six-grade children. J Am Diet Assoc 2011; 111:431–436.<br />

21. Strauss RS, Pollack HA. Social marginalization of overweight children.<br />

Arch Pediatr Adolesc Med 2003; 157:746–752.<br />

22. Puhl RM et al. Weight-based victimization toward overweight<br />

adolescents: observations <strong>and</strong> reactions of peers. J Sch <strong>Health</strong> 2011;<br />

81:696–703.<br />

23. US Department of <strong>Health</strong> <strong>and</strong> Human Services. Preventing tobacco<br />

use among youth <strong>and</strong> young adults: A report of the surgeon general.<br />

Atlanta, GA. US Department of <strong>Health</strong> <strong>and</strong> Human Services, Centers <strong>for</strong><br />

Disease Control <strong>and</strong> Prevention, National Center <strong>for</strong> Chronic Disease<br />

Prevention <strong>and</strong> <strong>Health</strong> Promotion, Office on Smoking <strong>and</strong> <strong>Health</strong>, 2012.<br />

Available at: http://www.surgeongeneral.gov/library/reports/preventingyouth-tobacco-use/index.html<br />

Accessed July 11, 2012.<br />

24. Centers <strong>for</strong> Disease Control <strong>and</strong> Prevention. Youth <strong>and</strong> tobacco use.<br />

February 2012. Available at: http://www.cdc.gov/tobacco/data_<br />

statistics/fact_sheets/youth_data/tobacco_use/index.htm. Accessed<br />

July 11, 2012.<br />

25. Centers <strong>for</strong> Disease Control <strong>and</strong> prevention. Sexual risk behavior: HIV, STD<br />

& teen pregnancy prevention. June 2012. Available at: http://www.cdc.<br />

gov/<strong>Health</strong>yYouth/sexualbehaviors/index.htm. Accessed July 20, 2012.<br />

26. Centers <strong>for</strong> Disease Control <strong>and</strong> Prevention. Genital HPV Infection CDC<br />

Fact Sheet. February 2012. Available at: http://www.cdc.gov/std/HPV/<br />

STDFact-HPV.htm. Accessed July 20, 2012.<br />

27. U.S. Department of <strong>Health</strong> <strong>and</strong> Human Services. How tobacco<br />

smoke causes disease: the biology <strong>and</strong> behavioral basis <strong>for</strong> smokingattributable<br />

disease: A report of the surgeon general. Atlanta, GA: US<br />

Department of <strong>Health</strong> <strong>and</strong> Human Services, Centers <strong>for</strong> Disease Control<br />

<strong>and</strong> Prevention, National Center <strong>for</strong> Chronic Disease Prevention <strong>and</strong><br />

<strong>Health</strong> Promotion, Office on Smoking <strong>and</strong> <strong>Health</strong>, 2010.<br />

28. U.S. Department of <strong>Health</strong> <strong>and</strong> Human Services. The health consequences<br />

of involuntary exposure to tobacco smoke: A report of the surgeon<br />

general – executive summary. US Department of <strong>Health</strong> <strong>and</strong> Human<br />

Services, Centers <strong>for</strong> Disease Control <strong>and</strong> Prevention, Coordinating Center<br />

<strong>for</strong> <strong>Health</strong> Promotion, National Center <strong>for</strong> Chronic Disease Prevention <strong>and</strong><br />

<strong>Health</strong> Promotion, Office on Smoking <strong>and</strong> <strong>Health</strong>, 2006.<br />

29. National Cancer Institute. HPV <strong>and</strong> cancer. Available at: http://www.<br />

cancer.gov/cancertopics/factsheet/Risk/HPV. Accessed July 20, 2012.<br />

30. Chaffee BW, Weston SJ. Association between chronic periodontal<br />

disease <strong>and</strong> obesity: A systematic review <strong>and</strong> meta-analysis.<br />

J Periodontol 2010; 81:1708–1724.<br />

31. Lalla E et al. Periodontal changes in children <strong>and</strong> adolescents with<br />

diabetes. Diabetes Care 2006; 29:295–299.<br />

32. Heikkinen AM et al. The effect of smoking on periodontal health of 15-16<br />

year-olds. J Periodontol 2008; 79:2042–2047.<br />

33. Mealey BM, Oates TW. AAP-commissioned review: Diabetes mellitus ad<br />

periodontal disease. J Periodontol 2006; 77:1289–1303.<br />

34. Johnson G, Hill M. Cigarette smoking <strong>and</strong> the periodontal patient.<br />

J Periodontol 2004; 75:196–209.<br />

35. Thomson WM et al. Cannabis smoking <strong>and</strong> periodontal disease among<br />

young adults. JAMA 2008; 299:525–531.<br />

36. Dye BA et al. Trends in oral health status; United States, 1988-1994 <strong>and</strong> 1999-<br />

2004. National Center <strong>for</strong> <strong>Health</strong> Statistics. Vital <strong>Health</strong> Stat 2007; 11:248.<br />

37. Centers <strong>for</strong> Disease Control <strong>and</strong> Prevention: Untreated dental caries<br />

(cavities) in children ages 2-19, United States. February 2011. Available<br />

at: http://www.cdc.gov/features/dsuntreatedcavitieskids/. Accessed<br />

July 23, 2012.<br />

38. Fontana M, Zero D. Assessing patients’ caries risk. JADA 2006; 137:1231–1239.<br />

39. Lim S et al. Cariogenicity of soft drinks, milk <strong>and</strong> fruit juice in low-income<br />

African American children. A longitudinal study. JADA 2008; 139:959–967.<br />

40. Modeer T et al. Associations between obesity, flow rate of whole saliva,<br />

<strong>and</strong> dental caries in adolescents. Obesity 2010; 18:2367–2373.<br />

41. Aligne CA et al. Association of pediatric dental caries with passive<br />

smoking. JAMA 2003; 289:1258–1264.<br />

42. American Cancer Society. <strong>Oral</strong> cancer <strong>and</strong> oropharyngeal cancer<br />

Available at: http://www.cancer.org/acs/groups/cid/documents/<br />

webcontent/003128-pdf.pdf Accessed July 23, 2012.<br />

43. D’Souza G et al. Case-control study of human papillomavirus <strong>and</strong><br />

oropharyngeal cancer. N Engl J Med 2007; 356:1944–1956.<br />

44. Majeski J. CRA/CAMBRA <strong>and</strong> the dental hygiene process of care.<br />

Access 2009; 23:20–25.<br />

45. Hujoel PP et al. Dental flossing <strong>and</strong> interproximal caries: A systematic<br />

review. J Dent Res 2006; 85:298–305.<br />

46. American Dental Association Council on Scientific Affairs. Professionally<br />

applied topical fluoride: Evidence-based clinical recommendations.<br />

JADA 2006; 137:1151–1159.<br />

47. Beauchamp J et al. Evidence-based clinical recommendations <strong>for</strong><br />

the use of pit-<strong>and</strong>-fissure sealants. A report of the American Dental<br />

Association Council on Scientific Affairs. JADA 2008; 139:257–268.<br />

48. Oong EM et al. The effect of dental sealants on bacterial levels in<br />

carious lesions. JADA 2008; 139:271–278.<br />

49. Mäkinen KK. Sugar alcohols, caries incidence, <strong>and</strong> remineralization of caries<br />

lesions: A literature review. Int J Dent 2010; 981072. Epub 2010 Jan 5.<br />

50. Goyal CR et al. The addition of a water flosser to power tooth brushing:<br />

Effect on bleeding, gingivitis, <strong>and</strong> plaque. J Clin Dent 2012, 23:57–63.<br />

51. Barnes CM et al. Comparison of irrigation to floss as an adjunct to<br />

toothbrushing: Effect on bleeding, gingivitis, <strong>and</strong> supragingival plaque.<br />

J Clin Dent 2005; 16(3):71–77.<br />

52. Sharma et al. The effect of a dental water jet with orthodontic tip on<br />

plaque <strong>and</strong> bleeding in adolescent patients with fixed orthodontic<br />

appliances. Am J Orthod Dentofacial Orthop 2008, 133:565–571.<br />

53. Rosema NAM et al. The effect of different interdental cleaning devices<br />

on clinical parameters. Presented at IADR, Barcelona, Spain, July 17,<br />

2010. Abstract #3797.<br />

54. Gorur A et al. Biofilm removal with a dental water jet. Compend Contin<br />

Educ Dent 2009; 30(Suppl 1):1–6.<br />

55. Al-Mubarak S et al. Comparative evaluation of adjunctive oral irrigation<br />

in diabetes. J Clin Periodontol 2002; 29:295.<br />

10


Post test Course #12–22<br />

<strong>Child</strong> <strong>and</strong> <strong>Adolescent</strong> <strong>Health</strong>:<br />

<strong>Implications</strong> <strong>for</strong> <strong>Oral</strong> <strong>Health</strong> Care Practitioners<br />

1. What percent of children who were obese between<br />

the ages of ten <strong>and</strong> fifteen years became obese adults<br />

twenty-five years later?<br />

a. 25%<br />

b. 40%<br />

c. 60%<br />

d. 80%<br />

2. The average daily intake of added sugar is:<br />

a. 12.3 teaspoons<br />

b. 22.2 teaspoons<br />

c. 30.5 teaspoons<br />

d. 38.1 teaspoons<br />

3. A child whose weight falls between the 85th <strong>and</strong> 95th<br />

percentile is considered:<br />

a. Underweight<br />

b. Normal weight<br />

c. Overweight<br />

d. Obese<br />

4. How many overweight adolescents are thought to<br />

have prediabetes?<br />

a. 1 in 3<br />

b. 1 in 6<br />

c. 1 in 10<br />

d. 1 in 15<br />

5. A recent study of children ages six to nineteen years with<br />

obesity <strong>and</strong> atherosclerotic risk factors found that seventyfive<br />

percent had carotid artery intima media thickness<br />

comparable to a __ year old.<br />

a. 25<br />

b. 35<br />

c. 45<br />

d. 55<br />

6. Non Alcoholic Fatty Liver Disease (NAFLD) is a condition<br />

where there is excess fat in the liver of people who generally:<br />

a. Drink little or no alcohol<br />

b. Eat little or no trans fats<br />

c. Are underweight<br />

d. Are over the age of 65<br />

7. Data found that __ of overweight students have been teased<br />

in a mean way while per<strong>for</strong>ming physical activities.<br />

a. 25%<br />

b. 65%<br />

c. 84%<br />

d. 99%<br />

8. What percentage of children under age eighteen are exposed<br />

to second-h<strong>and</strong> smoke?<br />

a. 22%<br />

b. 32%<br />

c. 42%<br />

d. 52%<br />

9. Which conditions have been associated with early<br />

periodontal disease in adolescents <strong>and</strong> young adults?<br />

a. Obesity<br />

b. Diabetes<br />

c. Smoking<br />

d. All of the above<br />

10. HPV DNA can be found in about two out of three cases of<br />

oral cancers. HPV-related cancer is more likely to be found in<br />

the oropharynx, especially the tonsils.<br />

a. Both statements are true<br />

b. Both statements are false<br />

c. The first statement is true, the second is false<br />

d. The first statement is false, the second is true<br />

11. Fluoride varnish is an effective caries prevention tool.<br />

Fluoride varnish takes less time to apply, creates less<br />

discom<strong>for</strong>t <strong>and</strong> has greater patient acceptability.<br />

a. Both statements are true<br />

b. Both statements are false<br />

c. The first statement is true, the second is false<br />

d. The first statement is false, the second is true<br />

12. Which statement is true?<br />

a. In the first year after a sealant is placed, caries reduction<br />

is eighty-six percent<br />

b. Sealant placement is associated with a reduction in<br />

restorative procedures<br />

c. Placing a sealant over existing caries does not increase<br />

viable bacteria or caries potential of the lesion<br />

d. All of the above<br />

13. People with diabetes who used a Water Flosser reduced<br />

gingival bleeding by __ percent.<br />

a. 44%<br />

b. 34%<br />

c. 24%<br />

d. 0%<br />

14. In adolescents with fixed orthodontic appliances, the Water<br />

Flosser removed __ times as much plaque as string floss.<br />

a. 1<br />

b. 2<br />

c. 3<br />

d. 4<br />

15. The Water Flosser is clinically proven to be an easier, more<br />

effective alternative to string floss. The Water Flosser has<br />

been shown to remove 99.9% of plaque biofilm from<br />

treated areas.<br />

a. Both statements are true<br />

b. Both statements are false<br />

c. The first statement is true, the second is false<br />

d. The first statement is false, the second is true<br />

11


Obtaining Continuing<br />

Education Credits<br />

Credits: 3 hours<br />

If you have questions about acceptance of continuing<br />

education (CE) credits, please consult your state or provincial<br />

board of dentistry.<br />

Directions:<br />

• Fill out the Water Pik CE Registration Form <strong>and</strong> Answer Sheet.<br />

• Answers should be logged on the answer sheet. Please<br />

make a copy of your post-test <strong>and</strong> answer sheet to retain<br />

<strong>for</strong> your records.<br />

• Only one original answer sheet per individual will be accepted.<br />

• Answers left blank will be graded as incorrect.<br />

• Please fill out the course evaluation portion.<br />

• The post-test may be submitted via mail, fax, or email to:<br />

Water Pik, Inc<br />

1730 East Prospect Road<br />

Fort Collins CO 80553<br />

Attn: Continuing Education Self Study Program<br />

Fax: 1-970-221-6075<br />

Email: ce@waterpik.com<br />

Scoring:<br />

In order to receive credit, you must answer 10 of the 15<br />

questions correctly.<br />

Results:<br />

By email: 6 weeks<br />

(Please make sure your email address is legible).<br />

By mail: 8-10 weeks<br />

Questions regarding content<br />

or applying <strong>for</strong> credit?<br />

Contact: Carol Jahn, RDH, MS, by email:<br />

cjahn@waterpik.com or phone: 630-393-4623<br />

Academy of General Dentistry Approved<br />

PACE Program Provider FAGD/MAGD Credit.<br />

Approval does not imply acceptance by a<br />

state or provincial board of dentistry or AGD<br />

endorsement. The current term of approval<br />

extends from 06/01/2010–05/31/2014.<br />

CE REGISTRATION FORM<br />

AND ANSWER SHEET<br />

Course #12–22: <strong>Child</strong> <strong>and</strong> <strong>Adolescent</strong> <strong>Health</strong>:<br />

<strong>Implications</strong> <strong>for</strong> <strong>Oral</strong> <strong>Health</strong> Care Practitioners<br />

Name:<br />

Credentials:<br />

Street Address:<br />

City:<br />

State:<br />

Email:<br />

Day Phone:<br />

Zip:<br />

@<br />

Cell or Home Phone:<br />

Answer Sheet<br />

Please circle the correct answer <strong>for</strong> each question.<br />

1. a b c d<br />

2. a b c d<br />

3. a b c d<br />

4. a b c d<br />

5. a b c d<br />

6. a b c d<br />

7. a b c d<br />

8. a b c d<br />

9. a b c d<br />

10. a b c d<br />

11. a b c d<br />

12. a b c d<br />

13. a b c d<br />

14. a b c d<br />

15. a b c d<br />

Course Evaluation<br />

Circle your response: 1 = lowest, 5 = highest<br />

Course objectives were met<br />

1 2 3 4 5<br />

Content was useful<br />

1 2 3 4 5<br />

Questions were relevant<br />

1 2 3 4 5<br />

Rate the course overall<br />

1 2 3 4 5<br />

How did you acquire this course:<br />

Internet DVD Tradeshow CE H<strong>and</strong>out Other____<br />

PN 20010520-STD -<br />

FN 20010520STD-F AE

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