Pediatric Hematology & Oncology

Objectives

• Pediatric oral health issue descriptions
• Diagnose and treat common oral health issues encountered in primary care
• Demonstrate fluoride varnish application

Oral Health in Primary Care

• Six infant primary care visits are scheduled during the first year of life
• Dental visits are not scheduled in the first year
• The AAP recommends children have their first dental visit by age 1

Barriers to Dental Care for Children

• Living in a rural area
• Not all dentists accept Medicaid
• Cultural beliefs
• Parental dental anxiety
• Lack of knowledge

Dental Caries

• Ranked as the #1 chronic preventable childhood disease
• 25% of children/adults have uncared for caries
• 90% of adults aged 20-64 years have had decay
• Dental caries are 5x more common than asthma
• Seven times more common than allergies
• Most prevalent in smokers, those with low income, and those with less education

Risk Factors for Dental Caries

• Approximately 50% is attributable to mother-child transmission
• Transmission is higher when the mother or primary caregiver had active decay in the past 12 months.
• Mother or primary caregiver does not have a dentist.
• Continual and bedtime bottle/sippy cup use with fluid other than water increases risk
• Frequent sugary snacks or fluids between meals increases risk
• Special needs children are at higher risk

Early Childhood Caries (ECC)

• Early development of caries increases the risk of rampant disease where caries may develop at less than 1 year of age
• Occurs 32 times more in infants born to mothers of low socioeconomic status, those with low educational levels, and those who consume high carbohydrate foods/fluids

Dental Caries and Children

• Associated with poor growth.
• 1 in 5 children aged 6-11 have tooth decay requiring treatment
• Treatment may require going to out-patient surgery or the hospital.
• Minority and ethnic groups have a higher prevalence, being five times more likely to have decay in permanent teeth

Oral Issues in School Aged Children

• 34 million school hours are lost per year due to dental problems
• Students with toothaches are nearly 4 times more likely to have a low-grade point average.
• Parents average 2.5 absent days from work or school per year
• Poor oral health creates barriers to academic success through distraction from pain and absenteeism.

Tooth Anatomy

• Enamel is the hardest substance in the body.
• Dentin is a tubular, calcified structure connecting enamel and pulp.
• Pulp contains vessels and nerves that keep the tooth alive
• Periodontal ligaments are bands of collagen tissue connecting the tooth root to the surrounding bone

Caries Pathophysiology

• Streptococcus mutans in plaque, metabolizing sugars, and reduced saliva flow are key components.

Impact of Saliva pH on Caries Development

• Low pH in saliva, frequent feedings with carbohydrates, and bacterial proliferation all contribute

Tooth Enamel and Eating

• The oral environment becomes more acidic during eating.
• Normal pH returns in approximately 30 minutes.
• The enamel needs around two hours for a full repair

White Spot Lesions

• Demineralization of the tooth causes a white spot lesion.
• Early signs of decay
• Topical fluoride varnish remineralizes and prevents decay

White Spot and Carious Lesions - Causes and Solutions

• Causes: Low pH of saliva, overgrowth of biofilm (plaque), demineralization of tooth and poor dietary habits
• Solutions: Neutralize with baking soda rinse, anti-microbial rinse (chlorhexidine 0.12%, sodium hypochlorite 0.2%), remineralize with fluoride and xylitol gum, involve the whole family

Early Childhood Caries (ECC) Equation

• ECC = Bacteria passed from mother/caregiver + Frequent exposure to sugary liquids + No dental hygiene

Consequences of Severe ECC

• Untreated childhood caries can result in disseminated infections, i.e. brain or sinus abscesses, cardiac and respiratory diseases
• Chronic caries and oral health disease may extend into adulthood

Overall Health Issues Due to Caries

• Speech development issues
• Orthodontic problems
• Self-esteem concerns Early or late eruption of permanent teeth High risk for caries in permanent teeth
• Possible nutritional issues – lack of protein intake

Oral Exam - The Four Ls

• Lift/Lower the Lips
• Look at Teeth
• Lap around the gums, palate, under the tongue
• Lasso the Tongue

Lip Licker's Dermatitis

• Minimize licking of lips
• Apply over-the-counter hydrocortisone ointment to affected areas twice a day
• Apply Aquaphor ointment hourly or urge to lick lips

Management of Oral Candidiasis

• Infants: Mycostatin 100,000u/mL, 2 mL QID x 7-10 days
• Children: Nystatin 1:100,000 U/mL; 5 mL swish for 30 seconds or longer, then swallow 4 times/day x 14 days (Pregnancy Category A)
• Older children/adolescents: Clotrimazole 10 mg troches/lozenges; suck one 5 times/day x 14 days (Do NOT chew, Pregnancy Category C)

Xerostomia in Children

• Recommend sugar-free candies or gum with xylitol, frequent sips of water, sugar-free chewing gum, and PerioWash for children

Gingivitis

• Treat with Chlorhexidine 0.12% rinse BID for patients with gingivitis or unable to brush due to periodontal surgery or jaw fracture

Gingival Hyperplasia

• Caused by poor oral hygiene, Dilantin, Cyclosporine, and Calcium Channel Blockers
• Sometimes drugs can be altered
• Treatment is painful, and reoccurrence is expected unless cause is removed.

Fluorosis - Causes

• Caused by excessive fluoride exposure during permanent teeth development
• Excess consumption of fluoridated toothpaste before ability to expectorate
• No treatment is required

Progression to Periodontitis

• Generally starts with healthy gums, and can advance through gingivitis, early periodontitis, moderate periodontitis, and advanced periodontitis

Congenital Abnormalities - Neonatal Teeth

• Present at birth or shortly after
• Extra teeth
• Low risk of aspiration
• Extract if: Irritating babies, inhibiting ability to feed, and irritation of mother while breastfeeding

Bruxism

• No treatment for primary teeth is needed
• Growth patterns do not allow for night guards
• Not a predictor of wear on permanent teeth in the future

Dental Appliances

• Braces: Risk for white spot lesions/decay
• Partials, Dentures, Retainers: Risk for candidiasis and unobserved lesions
• Asking patient to remove unfixed appliances is part of assessment
• Observe oral mucosa and assess for candidiasis or painless malignancies
• Treatment is removal of appliance and to brush teeth and appliance twice daily

Oral Care after Emesis

• Prevention of dental enamel erosion is done by rinsing with 1 tsp of baking soda/8 oz. water and spit; then 30 min. later, brush with fluoridated toothpaste after
• May need Rx high fluoride toothpaste for patients at risk

Substance Use Disorder

• Causes increased dental problems due to decreased salivary flow, bruxism (teeth grinding), high sugar intake, and disregard for oral hygiene
• FDA warning for Suboxone dissolved in mouth, rinse with take a large sip of water, swish gently around teeth and gums then, swallow, also brush teeth one hour later, and schedule regular dental visits

Normal Anatomy

• Geographic Tongue: Patterns on the tongue change weekly and are genetic
• Scalloped Tongue: Tongue is too large for mouth but is not pathological

HPV and Oral Cancer

• HPV is a very common virus
• 99% of the virus clears without any treatment
• Can cause oropharyngeal cancer in the back of the throat
• Causes 70% of oral cancers in the US
• HPV vaccine can prevent more than 90% of oral cancers caused by HPV
• Occurs 4:1 males to females

Oral Trauma

• Second most common reason for injury in children, making up 20% of all injuries in children less than six years
• Highest incidence at 2-3 years with motor coordination development.
• By 14 years, 1/3 of all children have experienced dental trauma
• There are 11,000 ER visits for dental trauma every year in children/teens
• Peak periods of injury 1-3 years in boys and girls
• Most common locations are home for girls and school for boys
• 60-75% of child abuse victims show head, face, and mouth injuries

Trauma

• Can result in dislocated or broken teeth
• Can be results of mandibular blows in the chin or lateral jaw

Media

• With Avulsion: Best recommend holding tooth gently by crown to rinse and then reimplnt
• Do not handle root
• Keep media cold like milk
• Poor ones are Dry-Saline-Tap Water > all poor

Extraoral Time and Prognosis

• The shorter, the better
• < 30 min 10% dental root resorption

• 90% dental root resorption

Mandibular Fractures

• Check condyles if chin hit.
• Check contralateral condyle and body of mandible if lateral jaw hit
• With fractured condyle the jaw deviates to the affected side
• Mandible is second most common fractured facial bone
• Condyle is most common sight
• 50% of mandible fractures are multiple
• Examine the injuries closely
• Be aware of Clinical Signs and Symptoms: malocclusion, ecchymosis in mouth floor

Temporomandibular Joint (TMJ) Assessment

• Observe TMJ for fractures and bruising that follows fractures
• Check external ear canal for blood and Deviation of bite
• Look for couple of teet that have first hit rather other teeth for a fractured mandible segment
• Palpation may reveal motility, and clicking, pouting which can be from fractured codyle or normal

Traumatic Dental Injuries: Provider’s Role

• History and assessments is crucial. Also the low awareness of the injuires has a poor diagnosis
• Care after is soft like yogurt or eggs, and the soft tooth brush and brush 2 to 3 times also do salt water rines for easliness
• Prevent infection with antimicrobial mouth wash
• Prevent injuries: Mouth guards.

Oral Trauma and Signs of Child Abuse

• Sexual Abuse: Ulcers and vesicles, erythea on soft and hard, differentiate all from truama lesions violent coughing and hemorragic
• Torn lingual and frenum , fractures - Look over and under mouth and inside cheek
• Trauma: the frenum scar is not cause by a fall" https://jada.ada.org/action/

New Baby Recommendations

• Avoid sharing after breast feed bottles, don't share bodily fluids or utensil, can prevent the transmission of the bacteria from mother to baby

Anticipatory Guidance

• Baby show show have a provider from age 1
• use fiorited water and varnish

Daily Care

• Brush after meal and floos, can begin that at age 7

Four B's for Bedtime

• Bathing and burring teeth will lead cueing for better sleep

Oral Health For Baby

• All baby get all primary teeth first Can be from drinking all sugar drinks
• Discourage drinks, food before bed, no bottles and more. Drink all meals all the time Avoid fluid sharing

Recommendations to Help

• Brush after teeth with soft
• May use fluids
• To better promote good habbits use the product and don't drink too much water
• Chew Gum > 1 ingredients all the all ingredient to have

What is Xylitol

• This subs can break Bacteria enamel
• Is safety and can help with to eat

Dental Sealent

• Deep is the best can stop bacteria

Myths About Fluids

• Is not a force meds Can be on our foods
• Can not make the cause fluorosis
• Not to babies, all studies said
• No connection or cancer

How does f fluids work

• Help make more strong It not make for the best of tooth

Knee exams

• Help look for better in all patients

Best Varnish

• Is the best with to get the quick
• There 3 with 6 to give

How to get it

• 2 year before 20 years
• For all those people with the varnish

Codes To give a CTP

• And the list can to help with billing Help code and all get bill Varnish help harden all the application
• Water or heat or brushing well

Community Help

• We have a lot of great provider help the patient For a quick service Give thanks with the local

Quick List with Oral Points

• Carrots are the best to get the teeth and mouth Fluoride can fix Is better help with gum. With facial. Help the teeth.
• A quick list to help the patient Help all the help patients

Iron Rich Foods

• Include red meat, polutry, seafood and eggs

Thalassemia Pearls

• Decreased or absent alpha or beta globin chains
• Affected Hgb unable to carry O2
• Mostly meditteranean, african and SE Asian descent
• Includes different categories: Alpha, which has silent carrier, minor, Hgb H disease, Hgb Bart's hydrops fetalis forms; and Beta, which has ineffective erythropoiesis with minor, intermedia and major categories
• Anemia or icreased count of RBC and iron studies
• Tests for hemolysis and can conduct lipid chromatography
• Treatment options depends on CBC and also depends on Ferritin

SCD Pearls

• Have Hgb S instead of Hgb A
• Have sticky, misshaped and short lived RBCs
• Can result from different categories: Have sticky, mis-shaped, short-lived RBCs, that results in hemolytic anemia with vaso-occulation
• Patient results and testing: Patient is asymptomatic, can show palor and have pain; also presents with fatigue. Can have severe anemia and result with Msk pain; dactylitis; bone infarction, Gallstones, seizures.
• Diagnose by having Low Hgb that has high reticulocytes and increased bilirubin, which can can result with a high kidney disease

VWD Pearls

• This is most common with factor VIII factor
• Treatment options depend on platelet count and depends on APT normal PT
• In this case, look out for the following factors: Prolonged platelet may not be affected. Anemia may be affected due to lack of factor VIII. Platelets may be normal

ALL and AML

These also relate to diseases. Important factors include test well and also do cbc from