Adolescent Oral Health Care: Latest Revision
Adolescent Oral Health Care: Latest Revision
Abstract
This best practice presents general recommendations for managing the distinct oral health care needs of adolescents. Accurate medical,
dental, and social histories are necessary for safe and effective care. Health history forms should allow youth to provide information on
topics such as gender, diet, piercings, and risk-taking behaviors (e.g., tobacco, alcohol, and drug use; sexual activity). Transgender and
gender diverse youth may be at increased risk for oral, physical, and psychosocial conditions (e.g., perimyolysis due to bulimia). The age
and stage of adolescence (early, middle, late) will impact diagnostic, preventive, and restorative treatment decisions. Each adolescent oral
health topic (caries, fluoride use, oral hygiene, diet management, sealants, professional preventive treatment, restorative dentistry, periodontal
disease, malocclusions, third molars, temporomandibular joint disorders, congenitally missing teeth, ectopic eruption, traumatic injuries,
and esthetic concerns) has specific recommendations. Assent is an important aspect of adolescent oral health care that can foster the
patient’s emerging independence. Transition to adult dental care should be discussed as the patient approaches the age of majority and
implemented at a time agreed upon by the patient, parent, and practitioner. Due to the complexity of their unique needs and psychosocial
influences, creating and maintaining trust and confidentiality are important when providing oral health care for adolescents.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs
and Scientific Affairs to offer updated information and recommendations regarding the management of oral health care for adolescents.
KEYWORDS: ADOLESCENT, ORAL HEALTH, ORAL SUBSTANCE ABUSE, RISK HEALTH BEHAVIOR, TONGUE PIERCING, TRANSITION TO ADULT CARE
Background
Adolescence refers to the period of accelerated biological ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. HPV: Human papil-
growth, changes, and social role transitions that bridges the
loma virus. NaF: Sodium fluoride OHRQoL: Oral health-related
gap from childhood to adulthood.3 The definition of adoles- quality of life. SHCN: Special health care needs. TMJ: Temporo-
cence has changed due to accelerated onset of puberty, delayed mandibular joint.
timing of role transitions (e.g., completion of education,
care. In some cases, the parent or family members are unaware Recommendation: The adolescent should receive maximum
of certain conditions affecting/facing the adolescent patient. fluoride benefit dependent on risk assessment:29,30
The dental practitioner needs to assure the adolescent patient • brushing teeth twice a day with a fluoridated dentifrice
of trust and confidentiality in certain situations. If the parent is recommended to provide continuing topical benefits.27
is unable to provide adequate details regarding a patient’s • professionally-applied fluoride treatments should be
medical history, consultation with the medical health care based on the individual patient’s caries-risk assessment,
provider may be indicated.12 as determined by the patient’s dental provider.27,29
There is a growing number of adolescents who experi- • home-applied prescription strength topical fluoride prod-
ence gender dysphoria and may be considering or undergoing ucts (e.g., 0.4 percent stannous fluoride gel, 0.5 percent
gender identity-related medical and health care services.13,14 fluoride gel or paste, 0.2 percent sodium fluoride [NaF]
The current prevalence of transgender and non-conforming rinse) may be used when indicated by an individual’s
youth is about two percent. 15 Health history forms should caries pattern or caries risk status.27
allow youth to provide information on gender, legal and pre- • systemic fluoride intake via optimal fluoridation of
ferred name, and preferred pronouns.16 Dental office staff drinking water or professionally-prescribed supplements
should determine preferences, and terminology used should be is recommended to 16 years of age. Supplements should
consistent by all staff. Transgender and gender diverse youth be given only after all other sources of fluoride have been
may be at increased risk for eating disorders or substance use evaluated.27
disorders.17,18 Special attention should be given to identifying
dental and systemic conditions that may be linked to such Oral hygiene: Adolescence can be a time of heightened caries
disorders. activity and periodontal disease due to an increased intake of
cariogenic substances and inattention to oral hygiene proce-
Recommendations dures.21 Adolescents become more independent and tooth-
This best practice addresses some of the special needs within the brushing may become less of a priority. Adolescent patients
adolescent population and proposes general recommendations need encouragement and motivation to brush with fluoridated
for their management. toothpaste and floss regularly. Discussions regarding oral
hygiene can highlight the benefit of the topical effect of
Caries fluoride, removal of plaque from tooth surfaces, and also
Adolescence marks a period of significant caries activity for decrease halitosis and improve esthetics.8,31
many individuals. Research suggests that the overall caries Recommendations:
rate is declining, yet remains highest during adolescence.19 1. Adolescents should be educated and motivated to main-
Immature permanent tooth enamel,20 a total increase in sus- tain personal oral hygiene through daily plaque removal,
ceptible tooth surfaces, and environmental factors such as diet, including flossing, with the frequency and technique
independence to seek care or avoid it, a low priority for oral based on the individual’s disease pattern and oral hygiene
hygiene, and additional social factors also may contribute to needs.31
the upward slope of caries during adolescence.21-25 Untreated 2. Professional removal of plaque and calculus is recom-
dental caries and missing teeth have been shown to have a neg- mended highly for the adolescent, with the frequency
ative impact on oral health-related quality of life (OHRQoL), of such intervention based on the individual’s assessed
however, restored teeth were not associated with worse risk for caries/periodontal disease as determined by the
OHRQoL.26 It is important for the dental provider to empha- patient’s dental provider.31,32
size the positive effects that fluoridation, professional topical
fluoride treatment, routine professional care, patient education, Diet management: Many adolescents are exposed to and con-
and personal hygiene can have in counteracting the changing sume high quantities of refined carbohydrates and acid-
pattern of caries in the adolescent population.6-8 containing beverages in the form of soda, high-energy sports
drinks, and junk food and with introduction of coffee.8,22,23,25,33
Management of caries The adolescent can benefit from diet analysis and modification.
Primary prevention Recommendation: Diet analysis, along with professionally-
Fluoride: Fluoridation has proven to be safe and highly effective determined recommendations for maximal general and dental
in prevention and control of caries.27 The adolescent can benefit health, should be part of an adolescent’s dental health man-
from fluoride throughout the teenage years and into early agement.34
adulthood.8 Although the systemic benefit of fluoride incor-
poration into developing enamel is not considered necessary Sealants: Sealant placement is an effective caries-preventive
past 16 years of age, topical benefits can be obtained through technique that should be considered on an individual basis.
optimally-fluoridated water, professionally-applied and pre- Sealants have been recommended for any tooth, primary or
scribed compounds, and fluoridated dentifrices.28,29 permanent, that is judged to be at risk for pit and fissure car-
ies.7,23,36-38 Caries risk may increase due to changes in patient
or habits that predispose to periodontal disease. Compre- maximize progress.56 Optimal oral hygiene and routine
hensive periodontal examination includes an assessment dental examinations are important to prevent deminer-
of gingival topography; probing depth; recession; attach- alization during orthodontic treatment.
ment levels; bleeding on probing; suppuration; furcation;
presence and degree of plaque, calculus, and gingival Third molars: Third molars can present acute and chronic
inflammation; mobility of teeth; periodontal charting; problems for the adolescent. Impaction or malposition leading
and radiographic periodontal diagnosis should be a to such problems as pericoronitis, caries, cysts, or periodontal
consideration when caring for the adolescent. The extent problems merits evaluation for removal.57-59 The role of the
and nature of the periodontal evaluation should be third molar as a functional tooth also should be considered.
determined professionally on an individual basis. Those Recommendations: Evaluation of third molars, including
patients with progressive periodontal disease should be radiographic diagnostic aids, should be an integral part of the
referred when the treatment needs are beyond the treating dental examination of the adolescent.31 Refer to the AAPD’s
dentist’s scope of practice.44,45,48,49 Best Practices on Management Considerations for Pediatric Oral
• appropriate evaluation for procedures to facilitate or- Surgery and Oral Pathology.57 Referral should be made if treat-
thodontic treatment including, but not limited to, tooth ment needs are beyond the treating dentist’s scope of practice.
exposure, frenectomy, fiberotomy, gingival augmentation,
and implant placement.45 Temporomandibular joint (TMJ) problems: Disorders of the
TMJ can occur at any age, but symptoms appear more prev-
Occlusal considerations alent in adolescence.60,61 A recent study reported that adolescent
Malocclusion can be a significant treatment need in the adoles- females had more TMJ disorders than males.52
cent population as both environmental and/or genetic factors Recommendations: Evaluation of the TMJ and related
come into play. Although the genetic basis of much maloc- structures should be a part of the examination of the adoles-
clusion makes it unpreventable, numerous methods exist to cent. An adolescent comprehensive dental examination should
treat the occlusal disharmonies, temporomandibular joint incorporate a screening evaluation of the TMJ and surrounding
dysfunction, periodontal disease, and disfiguration which may area to include a screening history for symptoms, clinical
be associated with malocclusion. Within the area of occlusal examination and evaluation of jaw movements and, if
problems are several tooth/jaw-related discrepancies that can indicated, radiographic imaging. Referral should be made
affect the adolescent. Third molar malposition and temporo- when the diagnostic and/or treatment needs are beyond the
mandibular disorders require special attention to avoid treating dentist’s scope of practice.57,60,61
long-term problems. Congenitally missing teeth present complex
problems for the adolescent and often require combined Congenitally missing teeth: The impact of a congenitally miss-
orthodontic, restorative, and prosthodontic care for satisfactory ing permanent tooth on the developing dentition can be
resolution. significant.62 When treating adolescent patients who are con-
genitally missing teeth, many factors (e.g., esthetics; patient
Malocclusion: Any tooth/jaw positional problems that present age; growth potential; orthodontic, periodontal, and oral
significant esthetic, functional, physiologic, or emotional dys- surgical needs) must be taken into consideration.56,62-64
function are potential difficulties for the adolescent. These can Recommendations: Evaluation for patients who are
include single or multiple tooth malpositions, tooth/jaw size congenitally missing permanent teeth should include both
discrepancies, and craniofacial disfigurements. Malocclusion immediate and long-term management. Referral should be
can affect the oral health quality of life for adolescents. Ado- made when the treatment needs are beyond the treating
lescents with Class II and III malocclusions or anterior overjet dentist’s scope of practice. Due to the complexity of the
greater than six millimeters reported a significant impact on growing adolescent, a team approach may be indicated.62,65
their oral health related quality of life.51-55
Recommendations: Ectopic eruption: Abnormal eruption patterns of the adoles-
1. Malposition of teeth, malrelationship of teeth to jaws, cent’s permanent teeth can contribute to root resorption, bone
tooth/jaw size discrepancy, skeletal malrelationship, or loss, gingival defects, space loss, and esthetic concerns. Early
craniofacial malformations or disfigurement that presents diagnosis and treatment of ectopically erupting teeth can re-
functional, esthetic, physiologic, or emotional problems sult in a healthier and more esthetic dentition. Prevention and
for the adolescent should be referred for evaluation when treatment may include extraction of deciduous teeth, surgical
the treatment needs are beyond the treating dentist’s intervention, and/or endodontic, orthodontic, periodontal,
scope of practice. and/or restorative care.66-68
2. Treatment of malocclusion by a dentist should be based Recommendations: The dentist should be proactive in diag-
on professional diagnosis, available treatment options, nosing and treating ectopic eruption and impacted teeth in
patient motivation and readiness, and other factors to the young adolescent.57 Early diagnosis, including appropriate
radiographic examination,38 is important. Referral should be upon correct diagnosis and consideration of eruption pattern
made when the treatment needs are beyond the treating den- of the permanent dentiton.76 The dentist must determine the
tist’s scope of practice.65 appropriate mode of treatment. Use of bleaching agents,
microabrasion, placement of an esthetic restoration, or a com-
Traumatic injuries bination of treatments all can be considered.77,78
Epidemiological studies have shown up to 25 percent of adol- Recommendations: For the adolescent patient, judicious
escents and adults experienced dental trauma, with most of use of bleaching can be considered part of a comprehensive,
these injuries involving maxillary central incisors from falls, sequenced treatment plan that takes into consideration the
collisions, playing sports, accidents, violence, or recreational patient’s dental developmental stage, oral hygiene, and caries
activities.69-71 The prevalence of injuries reported from studies status. A dentist should monitor the bleaching process, ensur-
around the world shows a wide range from six percent to 59 ing the least invasive, most effective treatment method. Dental
percent, depending on the country and type of injury.70 Dental professionals also should consider possible side effects when
traumatic injuries are associated mostly commonly with falls contemplating dental bleaching for adolescent patients.78-80
or collisions, and males are more frequently injured across all
age groups.69 All sporting activities have an associated risk of Tobacco, nicotine, alcohol, and recreational drug use: Signifi-
orofacial injuries due to falls, collisions, and contact with hard cant oral, dental, and systemic health consequences and death
surfaces.72 The administrators of youth, high school, and col- are associated with all current forms of tobacco use. These
lege organized sports have demonstrated that dental and facial include the use of products such as cigars, cigarettes, snuff,
injuries can be reduced significantly by introducing mandatory hookahs, smokeless tobacco, pipes, bidis, kreteks, dissolvable
protective equipment such as face guards and mouthguards.73 tobacco, and electronic cigarettes.81 Smoking and smokeless
Additionally, youth participating in leisure activities such as tobacco use are initiated and established primarily during
skateboarding, roller skating, trampolining, and bicycling also adolescence.82-85 There is increased risk in oral cancer from
benefit from appropriate use of mouthguards and protective chewing tobacco and an increased risk of lung and pancreatic
equipment.8,74,75 Long-term sequelae of traumatic injuries cancers, cardiovascular disease, stroke, and risk-taking behav-
can affect well-being, speech, need for complex care, and oral iors with use of nicotine, e-cigarettes, vaping, alcohol, and
health-related quality of life.8 recreational drugs.86 In addition, use of these substances can
Recommendations: Timely management of traumatic dental have effects such as halitosis, extrinsic staining, and negative
injuries is very important. There is a need for greater aware- outcomes in sports performance.8
ness of and education regarding the importance of timely Recommendations: The oral and systemic consequences of
management of dental trauma.69 Dentists should introduce a all current forms of tobacco use should be part of each pa-
comprehensive trauma prevention program to help reduce the tient’s oral health education.87-89 For those adolescent patients
incidence of traumatic injury to the adolescent dentition. This who use tobacco products, the practitioner should provide or
prevention plan should consider assessment of the patient’s refer the patient to appropriate educational and counseling
sport or activity, including level and frequency of activity.73 services.90 Questions regarding tobacco use should be added to
Once this information is acquired, recommendation and the adolescent dental record.91 When associated pathology is
fabrication of an age-appropriate, sport-specific, and properly- present, referral should be made if the treatment needs are
fitted mouthguard/faceguard can be initiated.73 Players should beyond the treating dentist’s scope of practice. This is further
be warned about altering the protective equipment that will discussed in the AAPD’s policies on tobacco use, nicotine
disrupt the fit of the appliance. In addition, players and delivery systems, and substance abuse.87-89
parents must be informed that injury may occur even with
properly-fitted protective equipment.73 Oral piercing: Intraoral and perioral piercing can have local
and systemic adverse effects.92,93 Risks include, but are not
Additional considerations in oral/health care of the adolescent limited to, pain, bleeding, swelling, hematoma, delayed healing,
The adolescent can present particular psychosocial character- nerve damage, abscess, blood-borne infections (hepatitis B or
istics that impact the health status of the oral cavity, care C, human immunodeficiency virus [HIV], Epstein-Barr virus
seeking, and compliance. The self-concept development pro- [EBV], tetanus, tuberculosis), endocarditis, metal hypersensi-
cess, emergence of independence, and the influence of peers tivity, choking from loose jewelry, enamel fractures, gingival
are just a few of the psychodynamic factors impacting dental trauma, periodontal recession, speech impediment, and swal-
health during this period.6,9,28 lowing difficulties or aspiration.8,93-95
Recommendations: Piercing and the use of jewelry on
Esthetic concerns: Desire to improve esthetics of the dentition intraoral and perioral tissues should be discouraged due to
by tooth whitening and removal of stained areas or defects can potential for pathologic conditions and sequelae.93 Prevention
be a concern of the adolescent. Indications for the appropriate of complications begins with oral health education regarding
use of tooth-whitening methods and products are dependent these adverse effects.95
to another practitioner, the dental home can remain with the Wellness. Ensuring comprehensive care and support for
pediatric dentist and appropriate referrals for specialized dental transgender and gender-diverse children and adolescents.
care should be recommended when needed.103 Pediatrics 2018;142(4):e20182162.
14. Kaltiala-Heino R, Bergman H, Tyolajarvi M, Frisen L.
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