Module 3: Oral Health Supervision
Special Care- Oral Health Supervision

3.5 Anticipatory Guidance

Parents of CSHCN frequently report that they receive little information about their child’s oral development and that they don’t feel confident in providing oral hygiene care at home. As part of health supervision, oral health professionals should provide parents with anticipatory guidance. Anticipatory guidance refers to key information about oral development, teething and tooth eruption, oral hygiene, feeding and eating practices, fluoride, and injury prevention provided to the family about the child’s current oral health and what to expect during the next developmental stage. Although anticipatory guidance for most children is based on chronological age, in CSHCN it is based on an overall assessment of the child’s growth and development and level of functioning in activities of daily living.

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How can parents provide effective oral hygiene care at home for their child with special health care needs?
Larry Salzmann, D.D.S. responds.

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Oral Health

The best way to involve parents in their child’s oral health is to improve their understanding of oral health, and increase their confidence in their ability to provide oral hygiene care for their child. The first step is to provide them with information about how to improve their own oral hygiene and answer their questions about oral health. The next step is to explain what to look for in their child’s mouth and how to do that. And the final step is to demonstrate appropriate oral hygiene care skills for both parents and the child. Ask parents to demonstrate how they clean and inspect their child’s mouth, and discuss problems they encounter. Brainstorm with parents to arrive at realistic solutions. Offer, with permission, modifications to make the process easier and more effective. Parents’ comfort level and the types of problems encountered will change as the child progresses through various developmental stages.

Oral health professionals can share educational resources with parents and children to foster optimal oral hygiene at home. (Also see Resources for Parents.)

Some of the following special situations may arise:

  • If oral motor dysfunction interferes with clearing food from the mouth or with oral hygiene care at home, consult with other members of the child’s health care team (e.g., physician, occupational or physical therapist), and advise the parents.
  • Children who cannot hold their mouths open to brush effectively may benefit from special aids such as a mouth prop, if it is used correctly and gently.

Examples of a mouth prop include

  • Three or four tongue depressors taped together
  • A rolled-up moistened washcloth
  • A reusable or disposable mouth prop

Nutrition

Feeding and eating problems—the inability or refusal to eat certain foods because of neuromotor dysfunction, obstructive lesions, taste or texture sensitivities, or psychological factors—are more common in CSHCN than in the general pediatric population.

Some contributors to nutritional problems that are common among CSHCN include the following:

  • To consume enough calories, children with neurological impairment may require prolonged feeding time and small, frequent meals and snacks, which extends the opportunity for an acidic environment to develop in the mouth.
  • Children with asthma often use a bronchodilator that can reduce saliva flow and may use steroid inhalers that can cause candidiasis. Other medications that cause dry mouth are antihistamines, antidepressants, antibiotics, and anti-gastroesophageal reflux agents. Obtaining adequate fluid intake is a common concern for CSHCN; inadequate fluid intake can lead to dehydration, resulting in reduced saliva flow. Reduced saliva flow increases the risk for dental caries.
  • Children with neurologic problems (e.g., cerebral palsy) may have feeding difficulties caused by a hyperactive gag reflex or ineffective sucking and swallowing. Poor muscle tone may also impair a child’s ability to chew and swallow. Although healthy infants typically outgrow gastroesophageal reflux, some children with special health care needs may experience reflux beyond infancy, which can cause dental enamel erosion, as gastric contents that are regurgitated into the mouth erode surface enamel and expose the dentin. Children may then experience sensitivity to hot and cold foods and, eventually, severe pain.

More contributors to nutritional problems that are common among CSHCN:

  • Medications can affect nutritional status. Several anti-seizure medications interfere with vitamin D and folate metabolism. Vitamin D deficiency hinders the absorption of calcium and phosphorus and thus interferes with the mineralization of bones and teeth. A deficiency of B complex vitamins, such as folate, may result in lesions on the lips or tongue, which may interfere with food and fluid intake.
  • Children with developmental delays may experience delays in development of feeding skills. Oral-motor activity involves body positioning, fine and gross motor skills, social interactions, and sufficient cognition, any of which may be negatively affected by a child’s overriding medical condition. Advise the parents that the child’s ability, not chronological age, should determine the oral feeding stage. However, infant foods are not nutrient-dense enough for older children, even if the texture is appropriate. Table foods that have been blended may be more appropriate but still could be nutrient deficient. Some children require supplemental feedings of high-calorie, nutrient-dense formulas, which can be highly cariogenic.
  • Behavioral problems may be common in CSHCN because of parent/child control issues at mealtimes. Advise parents to separate food-related behavior and parent-child interactions. Feeding can become more manageable when parents seek the support of an interdisciplinary feeding team that includes a behavioral specialist.
  • If children are unable or unwilling to participate in daily physical activity, they may become overweight, especially if they drink sugar-sweetened beverages, eat snacks frequently, and/or eat high-calorie foods.

In general, multidisciplinary involvement is critical to promote optimal nutritional status for CSHCN. Oral health professionals should coordinate dietary and feeding recommendations with a registered dietitian/nutritionist or other health professionals (e.g., occupational therapist, psychologist) involved in the child’s nutritional care.

Oral Trauma and Injury

Oral trauma and injury from falls or accidents are common among children, especially when they are learning to walk. However, they occur more frequently in children with balance problems, seizure disorders, or cerebral palsy. Emphasize to parents that injuries require immediate professional attention, and explain the following procedures to follow if a permanent tooth is knocked out:

Physical abuse, which is reported more frequently in CSHCN than in the general pediatric population, often presents as oral trauma. (See section 3.4, Child Abuse and Dental Neglect.)

Children who engage in self-injurious behaviors may be receiving care from a therapist or psychologist. If these harmful behaviors have not been diagnosed, refer the child to the primary care health professional, who will in turn make a referral for assessment and treatment. If appropriate, oral health professionals should recommend protective oral appliances to assist in combating self-injurious behavior. (See section 3.3, Oral Examination, Oral Trauma and Injury.)

Motivational Interviewing

More and more often, professionals are using motivational interviewing to help parents set goals for increasing their confidence and skills in oral care. Motivational interviewing facilitates behavior change by helping the child or parents explore and resolve their ambivalence about change. It is done in a collaborative style, which supports the autonomy and self-efficacy of the patient and uses the child’s or parents’ own reasons for change. It increases the child’s or parents’ confidence and reduces defensiveness. Motivational interviewing keeps the responsibility to change with the child and/or parent, which helps to decrease staff burnout. In dentistry, it is useful in counseling about brushing, flossing, fluoride varnish, reducing sugar-sweetened beverages, and smoking cessation. Open-ended questions, affirmations, reflective listening, and summarizing characterize the patient-centered approach. It is especially helpful in higher levels of resistance, anger, or entrenched patterns. Motivational interviewing is empowering to staff, child, and parents and by design is not adversarial or shaming. 6