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Journal for Specialists in Pediatric Nursing
ORIGINAL ARTICLE
Integrating oral health into pediatric nursing practice: Caring for kids where they live Shelley Spurr, Jill Bally, and Marcella Ogenchuk Shelley Spurr, PhD, RN, is an Assistant Professor; Jill Bally, PhD, RN, is an Assistant Professor; and Marcella Ogenchuk, PhD, RN, is an Assistant Professor, College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
Search terms Interprofessional practice, oral health, pediatric nursing. Author contact [email protected], with a copy to the Editor: [email protected] Acknowledgement No external or intramural funding was received. Disclosure: The authors report no actual or potential conflicts of interest. First Received June 19, 2014; Revision received January 9, 2015; Accepted for publication January 10, 2015.
Abstract Purpose. The purpose was to identify the factors influencing pediatric oral health and describe the Caring for Kids Where They Live program. Conclusions. In North America, the burden of pediatric oral disease is significant. Despite evidence to this effect, oral health is an often-neglected aspect of pediatric nursing care. The Caring for Kids Where They Live program has successfully integrated oral health into pediatric nursing care as evidenced by increased accessibility of health care, pathways for care, and disease prevention. Practice Implications. Pediatric nurses can address oral health disparities by integrating an oral health assessment tool as well as interprofessional follow-up and referral processes in practice.
doi: 10.1111/jspn.12108
Oral disease is pandemic in regions across the world (Petersen, 2009), with 60–90% of school children worldwide affected by oral health issues (World Health Organization, 2012). In Canada and the United States, dental disease is the leading pediatric chronic illness (Federal Provincial and Territorial Dental Working Group, 2012; National Children’s Oral Health Foundation, 2009). Approximately 17 million children live without dental care, and oral health is one of the leading causes of school absenteeism for children and adolescents each year (National Children’s Oral Health Foundation, 2009). An estimated 25–33% of Canadians are burdened with oral disease and have limited or no access to a dentist (Federal Provincial and Territorial Dental Working Group, 2012); in the United States, 19% of children have untreated cavities (National Center for Health Statistics, 2010). Oral health is an essential component of total health, and it can be a reliable and expedient indicator of general health in the pediatric population (Percy, 2008; Petersen, 2009). Oral health is defined Journal for Specialists in Pediatric Nursing 20 (2015) 105–114 © 2015, Wiley Periodicals, Inc.
as a state of the oral cavity and related tissues and structures that contributes positively to a person’s overall sense of wellness, in consideration of such factors as dental caries, oral diseases, oral infections and trauma, dental erosion, gingivitis, and periodontal disease (Canadian Dental Association, 2012c). Healthy teeth and periodontal tissue are required for chewing and digesting a variety of foods (Federal Provincial and Territorial Dental Working Group, 2012). The appearance of teeth is important in terms of self-esteem and perceptions of body image. Poor oral health can impact a child’s overall quality of life, inhibit cognitive and social development, and cause sleep deprivation, failure to thrive, malnourishment, and poor learning (Blevins, 2011; Federal Provincial and Territorial Dental Working Group, 2012). In addition, dental disease has been linked with heart disease, diabetes, and cancer (Blevins, 2011; National Children’s Oral Health Foundation, 2009). Despite this evidence, oral health has not been emphasized in nursing practice, education, and 105
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research. Rather, medical problems and other health issues common to pediatrics take priority (Blevins, 2011). Consequently, nurses may overlook or fail to respond to the oral health needs of children and adolescents. Pediatric nurses are uniquely positioned to provide oral health care by integrating an oral health assessment tool and interprofessional education follow-up and referral processes in practice. A recent literature review by Gillis and Mac Lellan (2010) reported a multitude of initiatives established in nursing programs whereby undergraduate students work in collaborative partnerships to address and respond to community needs. However, the only example of a program featuring a merger between nursing and dentistry programs appears to be at New York University (Iocopini, 2010). In this American collaborative practice, a reciprocal referral and consultation process was implemented to ensure seamless oral-systemic health care at a common site. The lack of published evidence-based collaborations to improve pediatric oral health illustrates the need to further identify and provide details of successful programs to guide pediatric nursing practice. This article reports factors influencing pediatric oral health and provides a comprehensive description of a unique collaboration between university-based nursing and dentistry programs entitled the Caring for Kids Where They Live program, which has been implemented in three schools in a western Canadian city. The many positive outcomes of this program— the first of its kind in its geographic region and in the pediatric population—are relevant to pediatric nurses who already practice in school settings around the world. This article also provides a novel pediatric oral health assessment guide, interprofessional follow-up and referral processes, and examples of successful outcomes. Nursing practice implications are also discussed.
FACTORS INFLUENCING THE ORAL HEALTH OF CHILDREN AND ADOLESCENTS
Over the past decade, lifestyles have rapidly changed with many health behaviors, including oral disease, now being linked to chronic illnesses (Petersen, 2009). A number of factors affect pediatric oral health, including socioeconomic status, oral hygiene, healthy eating, and diabetes, as well as adolescent risk behaviors, such as smoking, using smokeless tobacco, oral piercings, drug and alcohol usage, and unsafe oral sex practice (Federal 106
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Provincial and Territorial Dental Working Group, 2012; Petersen, 2009; Silk & Romano-Clarke, 2009). Socioeconomic status
Disadvantaged and socially marginalized populations bare the greatest burden of oral disease (Petersen, 2009). Recent studies have associated socioeconomic status with disparities in oral health among children and adolescents (Polk, Weyant, & Manz, 2010; Telford, Coulter, & Murray, 2011). The Canadian Dental Association (2012a) reported that poverty is a key social determinant of health, with families covered by provincial programs often having poor oral health; unhealthy eating patterns, inadequate oral hygiene practices, and other factors were found to specifically influence oral health. Children were explicitly identified as a population who experienced poor oral health due to lack of access to dental care. Oral health screening of lowincome families in the Canadian Prairies revealed obvious disparities in oral health outcomes; children from lower income neighborhoods had twice the number of decayed, missing/extracted, and filled teeth as children living in higher income neighborhoods (Dental Health Promotion Working Group of Saskatchewan: Data, Evaluation, and Research Task Group, 2011). Studies from the United States have similar results and predict that an estimated 44% of American children will develop dental disease before 5 years of age (National Children’s Oral Health Foundation, 2009). These studies clearly illustrate the direct influence of income on oral health outcomes in the pediatric population. Oral hygiene practice
Oral hygiene practice should include daily flossing and brushing with fluoridated tooth paste, establishing a dental home, and regular visits to the dentist (Silk & Romano-Clarke, 2009). However, many children and adolescents lack access to a dentist and essential oral hygiene products (Federal Provincial and Territorial Dental Working Group, 2012). Oral health attitudes, knowledge, and skills have been associated with oral hygiene status (Ericsson, Ostberg, Wennstrom, & Abrahamsson, 2012). Specifically, higher levels of plaque and gingivitis were significantly related to a lack of knowledge and less positive beliefs and perceptions of oral health. Infrequent tooth brushing, recent fillings/extractions, dental plaque, and irregular visits to the dentist all increase the risk of early childhood caries (Dental Journal for Specialists in Pediatric Nursing 20 (2015) 105–114 © 2015, Wiley Periodicals, Inc.
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Nutritional intake. Dental disease, such as dental erosion, caries, and periodontal disease, has been linked to diet (Dental Health Promotion Working Group of Saskatchewan: Data, Evaluation, and Research Task Group, 2011; Marrs et al., 2011; Perera & Ekanayake, 2010). The Canadian Dental Association (2012b) reported that the consumption of food frequently, over time, and that are low in nutritional value and high in carbohydrates, as well as sugary drinks such as fruit juices, energy drinks, and carbonated beverages, can cause significant caries and erosion to tooth enamel. Other researchers found that frequent consumption of surgery drinks (carbonated, sport, and energy drinks) and snacks led to sustained acid production, increased breakdown of tooth layers, dental caries, and significant long-term enamel dissolution (American Academy of Pediatrics, 2011; Silk & Romano-Clarke, 2009). These findings support the relationship between nutritional intake and oral health and provide direction regarding the need for a careful nutritional history and provision of adequate health education about nutrition.
indicated that an infective and inflammatory disease, such as periodontitis, can have significant health effects on individuals with diabetes due to their altered immune and healing ability. In a sample of adolescents with DM1, Orlando and colleagues (2010) found that less than half were aware that periodontal disease was associated with diabetes. Plaque and gingival indices as well as the saliva mutans streptococci count have been found to be significantly higher in diabetic children (ages 5–18 years) than in healthy children; no statistical difference was found among well, fairly, and poorly controlled diabetic children regarding caries experience, salivary microorganisms, plaque, and gingival indices (El-Tekeya, Tantawi, Fetouh, Mowafy, & Khedr, 2012). In spite of this evidence, the focus of diabetes management has been on screening for all complications except periodontal disease (Gillis, 2010). Oral health screening for diabetes can lead to early detection and prevention of complications. However, diabetes screening through an oral health exam has also been overlooked in pediatric nursing (Percy, 2008). Opportunistic infections such as oral candidiasis can present as a sign of systemic immunosuppression, which can be attributed to diabetes mellitus type 2 (DM2; Ship, 2003). Given the recent increase in prevalence of DM2 in the pediatric population, early detection is critical to glycemic control and to reduce long-term complications of this disease (Percy, 2008; Sellers, Panagiotopoulos, & Lawson, 2008; Ship, 2003).
Diabetes
Risk behaviors
Prevalence rates of diabetes mellitus are increasing among children and adolescents (Dyck, Osgood, Lin, Gao, & Stang, 2010). Over a decade ago, periodontal disease was coined the sixth complication of diabetes (Loe, 1993). Today, this disease remains a serious threat to the oral health of individuals. Current results suggest that type 1 diabetes mellitus (DM1) plays a significant role in dentition and oral health in children and adolescents (Orbak, Simsek, Orbak, Kavrut, & Colak, 2008). For example, Saes Busato, Bittencourt, Machado, Gregio, and Azevedo-Alanis (2010) investigated the association between metabolic control and oral health in adolescents aged 14–19 years who have DM1 and reported that the oral health of all adolescents with DM1 was impaired (with respect to the presence of oral lesions, caries experience, periodontal conditions, and salivary control rates). Similarly, Gillis (2010)
A number of risk behaviors influence the oral health of adolescents, but these risks can also be seen in younger children. These behaviors include tobacco, alcohol and drug use, oral piercings, and certain sexual activities. Heikkinen and colleagues (2012) found teenage smokers to be at higher risk for early development of periodontitis and, generally, poorer overall oral health than nonsmokers. Other authors concluded that tobacco, including smokeless tobacco, can cause oral cancer, tooth staining, and gum disease (Silk & Romano-Clarke, 2009). One potential reason for the increased risk in using smokeless tobacco is the significantly higher levels of nicotine compared with cigarettes (Percy, 2008). An oral health program in an urban Canadian city reported that adolescents who chewed tobacco had a 50% increased risk of oral cancer (Public Health-Oral Health Program, 2009b). Tobacco use
Health Promotion Working Group of Saskatchewan: Data, Evaluation, and Research Task Group, 2011; Marrs, Trumbley, & Malik, 2011). In a large quantitative study conducted with adolescents ages 12–18 years, adolescents from affluent families were at lower risk for poor oral hygiene behaviors, such as erratic brushing and irregular visits to the dentist (Park, Patton, & Kim, 2010).
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was directly linked with oral cancer, making early diagnosis and treatment essential to reduce the impact of the disease (Federal Provincial and Territorial Dental Working Group, 2012). Although prevalence rates for alcohol and marijuana use have declined in adolescent populations in recent years (Health Canada, 2012), alcohol use leads to other oral health complications such as soft tissue abnormalities, gingival inflammation, and significant levels of dental caries. Frequent use of alcohol dries out the oral cavity, discolors teeth, and erodes tooth enamel (Public Health-Oral Health Program, 2009b). Drugs such as ecstasy, cocaine, methamphetamine, and marijuana have been linked to periodontal and lip disease, bruxism, severe tooth erosions, gingivitis, and premature tooth loss (Silk & Romano-Clarke, 2009). Oral piercing is another significant factor influencing the oral health of adolescents. This fashion trend for many adolescents has led to an increased risk for oral infections and trauma to the mouth (Silk & Romano-Clarke, 2009). The skin and mucous membranes provide a natural barrier to many infections, and an oral piercing can have serious health consequences, including contraction of diseases such as hepatitis B and C, HIV, tooth chipping or cracking, cyst formation, speech impediments, and damage to gums and other soft tissues in the mouth (Public Health-Oral Health Program, 2009a). Furthermore, the increasing prevalence of oral sex in adolescents is contributing to an overall rise in sexually transmitted infections (STIs) that can be transmitted orally, including HIV, human papillomavirus, herpes simplex virus, chlamydia, gonorrhea, and syphilis (Percy, 2008). A recent American study investigating racial/ethnic differences in prevalence and patterns of oral sex found African American girls were significantly less likely to engage in oral sex than White or Hispanic girls, and that an oral sex history was associated with a six-factor increase in STI (Auslander, Biro, Succop, Short, & Rosenthal, 2009). These authors concluded that sexually experienced girls who engaged in oral sex were likely to engage in other risk behaviors and had greater rates of STIs. Thus, a significant body of research provides evidence to support an approach to pediatric nursing practice that includes oral health care as an essential component of overall health and wellness. While studies have examined the factors influencing pediatric oral health, few published articles have explored collaborations between nursing and dentistry to address this current pediatric health problem. 108
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THE CARING FOR KIDS WHERE THEY LIVE PROGRAM
The nursing faculty at University of Saskatchewan, Canada established an educational approach based on an interprofessional pediatric clinical learning experience titled Caring for Kids Where They Live (Ogenchuk, Spurr, & Bally, 2014). The Bachelor of Science in Nursing (BSN) program discussed in this article is a 3 + 1 year baccalaureate program. All pediatric clinical experiences are offered in the third year of the BSN program. The primary objectives of this partnership were to support an interprofessional clinical experience and to promote wellness in the physical, psychological, spiritual, and social dimensions of children’s and adolescents’ lives. This initiative was designed to develop a holistic approach to pediatric care (Spurr, 2009; Spurr, Bally, Ogenchuk, & Peternelj-Taylor, 2011). Throughout the school year, third-year nursing students along with a designated nursing faculty member were placed in school settings for a total of 78 hr over a varied time period. During the clinical learning experience, every student received teaching from a dentistry faculty member or public health oral health hygienist on concepts and procedures related to pediatric oral health care. The nursing students conducted comprehensive oral assessments through observation and discussion, and made referrals as appropriate. The program included several members of the health professions (nurses, dentists, and physicians) and teachers, support staff, and administrators in the school system. This learning environment involved a group of seven nursing students being placed in one of three designated urban schools (one elementary and two secondary) to complete their pediatric clinical experience. Each year, approximately three to four groups of nursing students are placed in each of the schools. The elementary school is comprised of students aged 5–13 years and the high school students are approximately 14–19 years old. The schools selected for the three pediatric clinical placements enroll students from core, inner city neighborhoods in an urban midwestern Canadian city. Lemstra, Neudorf, and Opondo (2006) remark that the magnitude of poor health outcomes in these communities is shocking for a city in a western nation. Specific to oral health, children from these core areas are less likely to be cavity-free (34.1%) than children attending schools from other neighborhoods (59.8%; Neudorf et al., 2012). Journal for Specialists in Pediatric Nursing 20 (2015) 105–114 © 2015, Wiley Periodicals, Inc.
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Procedures and ethical considerations for the oral health clinical experiences
Planning for the oral health experiences includes working with the school administration to prepare a list of school students who will be assessed in the oral health clinic. At the start of the academic year, all parents are informed in a school newsletter of the purpose and proposed activities of the Caring for Kids Where They Live program. In the elementary school, consents are signed by parents before students are seen by oral health professionals. For the high school students, parents are asked to contact the principal at the school if they do not support the participation of their son/daughter in this program. Consent is implied if the school does not hear from the parent/guardian. In addition, the nursing faculty is available to meet with parents who may have concerns or questions. Traditionally, ninth grade and kindergarten students have been chosen first for the assessments, as they are new to that school’s environment. Students in grades 10–12 are then offered the opportunity to attend the oral health clinics. However, any student in the participating schools can request to access the Caring for Kids Where They Live program at any time while the nursing students are present. The health clinics are held in a private room in the school. Prior to starting the assessment, the nursing students work to establish a safe and trusting environment for the school students; this includes a detailed explanation of the purpose of the clinic and the role of the nurses in the school. After this initial discussion, the school students are reminded that their participation in the program is optional and are advised to answer only the questions with which they are comfortable. School students are informed that all interactions during the clinic are confidential, except if there is evidence of or potential for selfharm and/or causing harm to someone else. Upon this disclosure, the nursing student and supervisor are required to report the information to the school administrators and counsellor. In addition, there is a chance that some of the questions could make the students feel uncomfortable. Students are told that they do not have to answer any question they are uncomfortable with or that they do not wish to answer. If a student does experience discomfort, they can contact the nursing supervisor at the school and arrangements can be made with the school counselor to follow up. All parents and school students are notified of their right to refuse to participate in the program. Refusal to participate has no Journal for Specialists in Pediatric Nursing 20 (2015) 105–114 © 2015, Wiley Periodicals, Inc.
bearing on the students’ academic standing in any way. All case files are stored in a locked cabinet in the school and are destroyed upon graduation or when the student no longer attends the school. Only the principal and nursing supervisor can access the case files. Oral health assessment and teaching
The oral health assessment of the school students is uniquely designed to consider all previously identified factors influencing oral health of children and adolescents, and extends significantly beyond oral hygiene and caries. The assessment begins with a developmentally appropriate health history that investigates a given student’s family history and personal experiences with diabetes, heart disease, cancer, or other medical challenges. In the case of an adolescent client (ages 12–19 years), risk behaviors are explored and include questions such as oral piercings, smoking, chewing tobacco products, drugs, alcohol, and sexual activity (specifically oral sex). The nursing student completes the history with questions related to dental hygiene. Examples include: Do you have dental coverage? When did you last see your dentist? Do you brush? How often? Do you floss your teeth? The oral health physical assessment conducted is age appropriate (Figure 1). The extraoral component includes a thorough examination for swelling, symmetry, and bruising. The intraoral assessment involves counting all teeth, assessing for holes or dark staining on biting surfaces, checking cheeks and tongue sides of teeth, and looking at the gums to identify the presence of bleeding, redness, and gum recession. The assessment also requires observing for bumps and lumps in the mouth, including the tongue, gums, and inner cheeks. This is done because the most frequent form of oral precancerous lesions (leukoplakia) appear as a white patch that cannot be rubbed off, and these generally appear in the buccal mucosa, lateral borders of the tongue, and floor of the mouth (Bratthall, Petersen, Stjernsward, & Brown, 2006). A final step includes noting fillings, previous dental work, appliances, and braces. Oral health teaching is completed immediately following the assessment and includes proper technique for brushing and flossing teeth, nutrition, and the provision of information related to establishing or maintaining a dental home. All students are also provided with appropriate health education resources and a new toothbrush. A more detailed assessment and teaching is provided for any student 109
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Caring for Kids Where They Live: Oral Health Assessment Guide Student Name:
Reference Priority: 1 2 3
Age:
Medical History: Allergies, Heart disease, Diabetes, Arthritis, and other medical problems. Health Behaviours: Drugs, Smoking, Chewing Tobacco, Alcohol, Oral Piercing, Oral Sex Do you have any oral piercings? Are you sexually active, and if so, are you having oral sex? Are you protecting yourself against sexually transmitted infections? Do you have any questions about birth control or sexually transmitted infections? In the past 12 months, how many cigarettes did you usually smoke per day? In the past 12 months, did you chew tobacco? In the past 12 months, how often did you drink alcohol (beer, wine, coolers, or hard liquor)? In the past 12 months, how often did you use cannabis? In the past 12 months, have you used inhalants to get high, or use cocaine, crack cocaine, crystal meth, tranquilizers, LSD, or amphetamines?
Dental Hygiene History When was your last dental visit? Who and where is your dentist? Do you have dental coverage? Do you brush your teeth? How often? Do you floss your teeth? How often? Do your teeth hurt? How often? When? Where? Do your teeth hurt when you drink something cold or hot?
Oral Health Physical Assessment Extra Oral: Assess face for symmetry, swelling, and bruising.
Intra Oral:
Figure 1 Caring for Kids Where They Live: Oral Health Assessment Guide. Note: Permission was granted for this adapted version from Dr. A. Koneru who was an Assistant Professor in Pediatric Dentistry at the University of Saskatchewan. LSD, lysergic acid diethylamide.
Count teeth (including if any wisdom teeth are present) and record if some teeth are missing. Record teeth with decay or any teeth that may have decay. Assess for any holes, dark staining on biting surfaces, cheek, and tongue side of teeth. Assess gums for bleeding, redness, and gum recession. Assess in mouth for any bumps or lumps, and sores. Assess tongue and lips (record any piercings). Pull cheeks away from teeth and assess inner cheeks and teeth. Note any fillings or any previous dental work. Note any braces or appliances.
Additional Notes from Assessment
Teachings, Recommendations, and Plan
Signature:
Date:
who identifies high-risk behaviors. If appropriate, the nursing students work with the school student to set realistic and individualized goals. Throughout the school year, the nursing students continue to follow these particular clients, including further assessment and intervention. General procedures for follow-up
After the nursing student completes the assessment, a dentist or dental therapist facilitates decisionmaking and follow-up procedures as needed. The school student is given a form to take home with the results of the assessment, and the nursing students record the assessment on another form that is kept at the school. As illustrated in Figure 2, each school student is assigned a reference number of one, two, or three, which provides a process for prioritizing 110
any follow-ups and referrals required. A number one signifies that the student has urgent oral health needs, and intervention is required in the immediate days following the clinic. A number two indicates that the school student has dental problems and should be followed in the future. A number three signifies that the student is being followed by, and has seen, a dentist in the last year and has no dental problems at the time of the assessment. Outcomes of the Caring for Kids Where They Live program
Since its inception, the Caring for Kids Where They Live program has experienced many successful outcomes. The number of school students assessed and the number of referrals vary by year and by school. In general, a group of seven nursing students can Journal for Specialists in Pediatric Nursing 20 (2015) 105–114 © 2015, Wiley Periodicals, Inc.
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Elementary School
High School
Number of School Students
60 Cases Requiring Urgent Dental Care
50 40 30 20
Cases Requiring Urgent Dental Care
10 0
Completed Oral Health Assessments
Completed Oral Health Assessments
Figure 2 Oral Health Assessments in Elementary and High School Students.
assess 35 school students during a 78-hr clinical experience and are required to follow up with at least one health issue for approximately 50–60% of these students. Outcomes of the school experiences are demonstrated in Figure 1. The follow-up for the school students can simply be a discussion about smoking cessation or checking to see if the student or parent/guardian made an appointment with the dentist. However, the nursing care that is required can also be extremely complex and urgent in nature. For example, one client requiring urgent oral health care had braces placed in his mouth in his home country 18 months prior to the student nurse assessment. The adolescent male had been living in Canada for over a year and, due to finances, had not yet visited an orthodontist. The nursing students immediately attempted to advocate for and intervene on behalf of this adolescent client by calling five local orthodontists who all refused to take the case due to insurance-related reasons. The dentist who had been volunteering from the local university was then contacted and was able to make arrangements for the client to be assessed by a university orthodontist. Regular appointments for assessment and revision of the adolescent’s braces were established along with affordable payments for the family. After the client had his first appointment, he came to thank the nursing students, saying “thank you, thank you, thank you. Now my mom does not have to cry every day because I have my braces on.” This heartfelt expression provided evidence of the difference that the Caring for Kids Where They Live program had made for this adolescent and his family. Journal for Specialists in Pediatric Nursing 20 (2015) 105–114 © 2015, Wiley Periodicals, Inc.
In another example, an oral assessment completed with a 6-year-old male student resulted in appropriate referral and treatment. The initial assessment included a visual examination of the child’s teeth. The nursing students identified that the young boy had one decayed tooth, two missing teeth, and seven capped teeth. The elementary school student was asked about his diet, oral health habits, and when he last saw a dentist. Although he did not recall when he visited the dentist, it was obvious that he had received previous care. A review of brushing techniques and flossing were provided because of the obvious tartar and plaque along his gum lines. He was also reminded to limit sugary treats and brush at least once a day, preferably before bed. The parents were notified about the new decay, which resulted in another cap on one of the teeth by the family dentist. This example demonstrates successful collaboration between the family and nursing students, and an opportunity for advocacy by the nursing students. Referrals
Another important component of the Caring for Kids Where They Live program was the development of methods for referrals to dentistry and orthodontists. Nursing students were able to work effectively with the school administration, families, and dentists to overcome barriers, including consent, finances, and transportation. For example, contact was initiated and information was provided to facilitate parental consent in order to proceed with necessary referrals. Ultimately, effective partnerships and pathways were developed to ensure follow-up care was provided to those children, adolescents, and families who were identified as requiring referrals. NURSING RESEARCH IMPLICATIONS
Future nursing research should explore which strategies might be most effective in teaching nurses to successfully incorporate oral health care into their nursing practice. Research should be conducted to include children of all ages and backgrounds, and in a variety of geographical areas, because these considerations play a significant role in the complex issues related to pediatric oral health. Pediatric nurses are leaders in pediatric health and well-being and, therefore, are strategically positioned to lead and conduct interprofessional, scientific research that will guide policy and improve holistic and 111
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comprehensive pediatric nursing care. This has the potential to significantly contribute to enhanced pediatric nursing care and broadly enhance oral health care and overall public health in pediatrics. CONCLUSION
Oral health has long been identified as an essential component of pediatric health. There is myriad evidence regarding the factors influencing oral health and the serious health effects of pediatric dental disease. Despite the identified importance of oral health, the focus of the literature and pediatric nursing practice has remained centered on medical problems, including common childhood illnesses. The Caring for Kids Where They Live program is an example of a collaboration that has successfully integrated oral health into pediatric nursing care. Evidence of positive outcomes includes accessibility of health care, establishing pathways for care, and oral health disease prevention, resulting in improved oral health and overall wellness for children and adolescents in school settings. Given the positive outcomes of the collaborative program, nurses are encouraged to support an approach to pediatric nursing practice that includes oral health care. Nurses should ensure that their clinical practice skills include the ability to advocate for and integrate oral health assessments, fluoride treatments, followup, and referrals into all pediatric care settings.
How might this information affect nursing practice?
Pediatric oral health is important and can impact quality of life for children and adolescents. Lowincome status, diabetes, oral hygiene, and other risk factors, particularly in adolescents, such as smoking, using smokeless tobacco, oral piercing, drug and alcohol use, and unsafe oral health practices, influence the burden of pediatric oral disease. Despite this knowledge, nurses in practice tend to focus on other medical problems and often overlook the oral health needs of children. In addition, there are few evidence-based guidelines for nurses who wish to address this prevalent pediatric chronic disease. Progress to improve the dismal pediatric oral health statistics in the twenty-first century will require nurses to recognize the importance of an integrated collaborative approach that is based on empirical research. The Caring for Kids Where They Live program is an example of an
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interprofessional collaboration that has successfully integrated oral health. This program has resulted in improved overall oral health for school children, including increased access to oral health care and establishing pathways for care, prevention, and treatment. Nurses are strategically positioned to promote oral health by (a) addressing the complex sociocultural factors that continue to support oral health disparities within the pediatric population; (b) using an oral health assessment tool, follow-up, and referral processes in pediatric nursing practice; and (c) creating partnerships between nursing and dentistry that address the current solitary nature of the provision of oral health care. Implementing a collaborative approach to pediatric oral health care can be a means to improve the overall health and quality of life of children and adolescents.
References American Academy of Pediatrics. (2011). Sports drinks and energy drinks for children and adolescents: Are they appropriate? Retrieved February 4, 2015, from http://pediatrics.aappublications.org/content/127/6/ 1182.full Auslander, B. A., Biro, F. M., Succop, P. A., Short, M. B., & Rosenthal, S. L. (2009). Racial/ethnic differences in patterns of sexual behavior and STI risk among sexually experienced adolescent girls. Journal of Pediatric and Adolescent Gynecology, 22(1), 33–39. Blevins, J. Y. (2011). Oral health care for hospitalized children. Pediatric Nursing, 37(5), 229–235, quiz 236. Bratthall, D., Petersen, P. E., Stjernsward, J. R., & Brown, L. J. (2006). Oral and craniofacial diseases and disorders. In A. D. Lopez, C. D. Mathers, M. Ezzati, D. T. Jamison, & C. J. Murray (Eds.), Disease control priorities in developing countries (2nd ed., pp. 723–736). Washington, DC: World Bank. Canadian Dental Association. (2012a). Access to oral health care for Canadians. Retrieved February 4, 2015, from http://www.cda-adc.ca/_files/position_statements/ accessToCarePaper.pdf Canadian Dental Association. (2012b). Junk food. Retrieved February 4, 2015, from http://www.cda-adc.ca/_files/ position_statements/junkFoodAndChildHealth.pdf Canadian Dental Association. (2012c). Oral health—good for life. Retrieved September 1, 2014, from http://www.cda -adc.ca/en/oral_health/cfyt/good_for_life/ Dental Health Promotion Working Group of Saskatchewan: Data, Evaluation, and Research Task Group. (2011). Spot light on oral health—special double
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digest. Retrieved October 1, 2014, from http://www.sdta.ca/mrws/filedriver/Spring_Spotlight _DHPWG_OF_SK.pdf Dyck, R., Osgood, N., Lin, T. H., Gao, A., & Stang, M. R. (2010). Epidemiology of diabetes mellitus among first nations and non-first nations adults. Canadian Medical Association Journal, 182(3), 249–256. El-Tekeya, M., Tantawi, M., Fetouh, H., Mowafy, E., & Khedr, N. (2012). Caries risk indicators in children with type 1 diabetes mellitus in relation to metabolic control. Pediatric Dentistry, 34(7), 510–516. Ericsson, J. S., Ostberg, A. L., Wennstrom, J. L., & Abrahamsson, K. H. (2012). Oral health-related perceptions, attitudes, and behavior in relation to oral hygiene conditions in an adolescent population. European Journal of Oral Sciences, 120, 335–341. Federal Provincial and Territorial Dental Working Group. (2012). Canadian oral health framework: 2013–2018. Retrieved February 4, 2015, from http://www.caphd .ca/sites/default/files/FrameworkOctober%202014%20 -%20FINAL%20English.pdf Gillis, A., & Mac Lellan, M. (2010). Service learning with vulnerable populations: Review of the literature. International Journal of Nursing Education Scholarship, 7(1), 1–27. Gillis, M. R. (2010). A place for oral health in diabetes management. Journal of the Canadian Dental Association, 76(a24), 1–3. Health Canada. (2012). Youth smoking survey 2010–11 data tables. Retrieved September 17, 2014, from http://www.yss.uwaterloo.ca/results/YSS2010-2011 _supplementary_tables_en.pdf Heikkinen, A., Pitkäniemi, J., Kari, K., Pajukanta, R., Elonheimo, O., Koskenvuo, M., & Meurman, J. H. (2012). Effect of teenage smoking on the prevalence of periodontal bacteria. Clinical Oral Investigations, 16, 571–580. Iocopini, A. (2010). Models for interprofessional practice: Innovative collaboration between nursing and dentistry. Journal of the Canadian Dental Association, 76(a16). Lemstra, M., Neudorf, C., & Opondo, J. (2006). Health disparity by neighbourhood income. Canadian Journal of Public Health, 97(6), 435–439. Loe, H. (1993). Periodontal disease. The sixth complication of diabetes mellitus. Diabetes Care, 16(1), 329–334. Marrs, J. A., Trumbley, S., & Malik, G. (2011). Early childhood caries: Determining the risk factors and assessing the prevention strategies for nursing intervention. Pediatric Nursing, 37(1), 9–15, quiz 16. National Center for Health Statistics. (2010). Health: United States 2009 with special feature on medical technology. Retrieved September 15, 2014, from http://www.cdc.gov/nchs/data/hus/hus09.pdf National Children’s Oral Health Foundation. (2009). America’s toothfairy: Because every child deserves a healthy
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smile. Retrieved November 2, 2012, from http://www.ncohf.org/why Neudorf, C., Muhajarine, N., Marko, J., Murphy, L., Macqueen Smith, F., Clarke, A., . . . Wu, J. (2012). Healthy families plus healthy communities equals healthy children: A report of the chief medical health officer on the health status and development of young children in Saskatoon health region, 2012. Retrieved November 2, 2012, from https://www.saskatoonhealthregion.ca/locations _services/Services/Health-Observatory/Documents/ Reports-Publications/Healthy_Families_Full_Report _2012.pdf Ogenchuk, M., Spurr, S., & Bally, J. (2014). Caring for Kids Where They Live: Interprofessional collaboration in teaching and learning in school settings. Nurse Education in Practice, 14(3), 293–298. doi:10.1016/ j.nepr.2013.11.003 Orbak, R., Simsek, S., Orbak, Z., Kavrut, F., & Colak, M. (2008). The influence of type-1 diabetes mellitus on dentition and oral health in children and adolescents. Yonsei Medical Journal, 49(3), 357–365. Orlando, V. A., Johnson, L. R., Wilson, A. R., Maahs, D. M., Wadhwa, R. P., Bishop, F. K., & Morrato, E. H. (2010). Oral health knowledge and behaviors among adolescents with type 1 diabetes. International Journal of Dentistry, 2010, 1–8. doi:10.1155/2010/942124 Park, Y. D., Patton, L. L., & Kim, H. Y. (2010). Clustering of oral and general health risk behaviors in Korean adolescents: A national representative sample. Journal of Adolescent Health, 47(3), 277–281. Percy, M. S. (2008). Oral health of adolescents–it’s more than dental caries. American Journal of Maternal Child Nursing, 33(1), 26–31. Perera, I., & Ekanayake, L. (2010). Relationship between dietary patterns and dental caries in Sri Lankan adolescents. Oral Health & Preventive Dentistry, 8(2), 165–172. Petersen, P. E. (2009). Global policy for improvement of oral health in the 21st century—implications to oral health research of World Health Assembly 2007, World Health Organization. Community Dentistry and Oral Epidemiology, 37, 1–8. Polk, D. E., Weyant, R. J., & Manz, M. C. (2010). Socioeconomic factors in adolescents’ oral health: Are they mediated by oral hygiene behaviors or preventive interventions? Community Dentistry and Oral Epidemiology, 38(1), 1–9. Public Health-Oral Health Program. (2009a). The piercing truth. Retrieved November 6, 2012, from https://www.saskatoonhealthregion.ca/locations _services/Services/Oral-Health/Documents/What%20 you%20Need%20to%20Know%20about%20Oral%20 Piercing.pdf Public Health-Oral Health Program. (2009b). Tooth tips for teens. Retrieved November 6, 2013, from
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https://www.saskatoonhealthregion.ca/locations _services/Services/Oral-Health/Documents/Tooth%20 Tips%20for%20Teens.pdf Saes Busato, I. M., Bittencourt, M. S., Machado, M. A., Gregio, A. M., & Azevedo-Alanis, L. R. (2010). Association between metabolic control and oral health in adolescents with type 1 diabetes mellitus. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics, 109(3), e51–e56. Sellers, E., Panagiotopoulos, C., & Lawson, M. (2008). Type 2 diabetes in children and adolescents. Canadian Journal of Diabetes, 32(Suppl. 1), S162–S167. Ship, J. (2003). Diabetes and oral health: An overview. Journal of the American Dental Association, 134(October), 4S–10S. Silk, H., & Romano-Clarke, G. (2009). The seven tenets to teen oral health. Contemporary Pediatrics, 26(6), 50–59.
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Spurr, S. (2009). Student perceptions of adolescent wellness. Doctoral Dissertation. Retrieved March 1, 2014, from http://library2.usask.ca/theses/available/ etd-07212009-140354/ Spurr, S., Bally, J., Ogenchuk, M., & Peternelj-Taylor, C. (2011). A wellness framework for pediatric nursing clinical practice. Holistic Nursing Practice, 25(6), 298–308. Telford, C., Coulter, I., & Murray, L. (2011). Exploring socioeconomic disparities in self-reported oral health among adolescents in California. Journal of the American Dental Association, 142(1), 70–78. World Health Organization. (2012). Media centre: Oral health. Fact sheet #318. Retrieved September 14, 2014, from http://www.who.int/mediacentre/factsheets/ fs318/en/
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Journal for Specialists in Pediatric Nursing
ORIGINAL ARTICLE
Integrating oral health into pediatric nursing practice: Caring for kids where they live Shelley Spurr, Jill Bally, and Marcella Ogenchuk Shelley Spurr, PhD, RN, is an Assistant Professor; Jill Bally, PhD, RN, is an Assistant Professor; and Marcella Ogenchuk, PhD, RN, is an Assistant Professor, College of Nursing, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
Search terms Interprofessional practice, oral health, pediatric nursing. Author contact [email protected], with a copy to the Editor: [email protected] Acknowledgement No external or intramural funding was received. Disclosure: The authors report no actual or potential conflicts of interest. First Received June 19, 2014; Revision received January 9, 2015; Accepted for publication January 10, 2015.
Abstract Purpose. The purpose was to identify the factors influencing pediatric oral health and describe the Caring for Kids Where They Live program. Conclusions. In North America, the burden of pediatric oral disease is significant. Despite evidence to this effect, oral health is an often-neglected aspect of pediatric nursing care. The Caring for Kids Where They Live program has successfully integrated oral health into pediatric nursing care as evidenced by increased accessibility of health care, pathways for care, and disease prevention. Practice Implications. Pediatric nurses can address oral health disparities by integrating an oral health assessment tool as well as interprofessional follow-up and referral processes in practice.
doi: 10.1111/jspn.12108
Oral disease is pandemic in regions across the world (Petersen, 2009), with 60–90% of school children worldwide affected by oral health issues (World Health Organization, 2012). In Canada and the United States, dental disease is the leading pediatric chronic illness (Federal Provincial and Territorial Dental Working Group, 2012; National Children’s Oral Health Foundation, 2009). Approximately 17 million children live without dental care, and oral health is one of the leading causes of school absenteeism for children and adolescents each year (National Children’s Oral Health Foundation, 2009). An estimated 25–33% of Canadians are burdened with oral disease and have limited or no access to a dentist (Federal Provincial and Territorial Dental Working Group, 2012); in the United States, 19% of children have untreated cavities (National Center for Health Statistics, 2010). Oral health is an essential component of total health, and it can be a reliable and expedient indicator of general health in the pediatric population (Percy, 2008; Petersen, 2009). Oral health is defined Journal for Specialists in Pediatric Nursing 20 (2015) 105–114 © 2015, Wiley Periodicals, Inc.
as a state of the oral cavity and related tissues and structures that contributes positively to a person’s overall sense of wellness, in consideration of such factors as dental caries, oral diseases, oral infections and trauma, dental erosion, gingivitis, and periodontal disease (Canadian Dental Association, 2012c). Healthy teeth and periodontal tissue are required for chewing and digesting a variety of foods (Federal Provincial and Territorial Dental Working Group, 2012). The appearance of teeth is important in terms of self-esteem and perceptions of body image. Poor oral health can impact a child’s overall quality of life, inhibit cognitive and social development, and cause sleep deprivation, failure to thrive, malnourishment, and poor learning (Blevins, 2011; Federal Provincial and Territorial Dental Working Group, 2012). In addition, dental disease has been linked with heart disease, diabetes, and cancer (Blevins, 2011; National Children’s Oral Health Foundation, 2009). Despite this evidence, oral health has not been emphasized in nursing practice, education, and 105
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research. Rather, medical problems and other health issues common to pediatrics take priority (Blevins, 2011). Consequently, nurses may overlook or fail to respond to the oral health needs of children and adolescents. Pediatric nurses are uniquely positioned to provide oral health care by integrating an oral health assessment tool and interprofessional education follow-up and referral processes in practice. A recent literature review by Gillis and Mac Lellan (2010) reported a multitude of initiatives established in nursing programs whereby undergraduate students work in collaborative partnerships to address and respond to community needs. However, the only example of a program featuring a merger between nursing and dentistry programs appears to be at New York University (Iocopini, 2010). In this American collaborative practice, a reciprocal referral and consultation process was implemented to ensure seamless oral-systemic health care at a common site. The lack of published evidence-based collaborations to improve pediatric oral health illustrates the need to further identify and provide details of successful programs to guide pediatric nursing practice. This article reports factors influencing pediatric oral health and provides a comprehensive description of a unique collaboration between university-based nursing and dentistry programs entitled the Caring for Kids Where They Live program, which has been implemented in three schools in a western Canadian city. The many positive outcomes of this program— the first of its kind in its geographic region and in the pediatric population—are relevant to pediatric nurses who already practice in school settings around the world. This article also provides a novel pediatric oral health assessment guide, interprofessional follow-up and referral processes, and examples of successful outcomes. Nursing practice implications are also discussed.
FACTORS INFLUENCING THE ORAL HEALTH OF CHILDREN AND ADOLESCENTS
Over the past decade, lifestyles have rapidly changed with many health behaviors, including oral disease, now being linked to chronic illnesses (Petersen, 2009). A number of factors affect pediatric oral health, including socioeconomic status, oral hygiene, healthy eating, and diabetes, as well as adolescent risk behaviors, such as smoking, using smokeless tobacco, oral piercings, drug and alcohol usage, and unsafe oral sex practice (Federal 106
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Provincial and Territorial Dental Working Group, 2012; Petersen, 2009; Silk & Romano-Clarke, 2009). Socioeconomic status
Disadvantaged and socially marginalized populations bare the greatest burden of oral disease (Petersen, 2009). Recent studies have associated socioeconomic status with disparities in oral health among children and adolescents (Polk, Weyant, & Manz, 2010; Telford, Coulter, & Murray, 2011). The Canadian Dental Association (2012a) reported that poverty is a key social determinant of health, with families covered by provincial programs often having poor oral health; unhealthy eating patterns, inadequate oral hygiene practices, and other factors were found to specifically influence oral health. Children were explicitly identified as a population who experienced poor oral health due to lack of access to dental care. Oral health screening of lowincome families in the Canadian Prairies revealed obvious disparities in oral health outcomes; children from lower income neighborhoods had twice the number of decayed, missing/extracted, and filled teeth as children living in higher income neighborhoods (Dental Health Promotion Working Group of Saskatchewan: Data, Evaluation, and Research Task Group, 2011). Studies from the United States have similar results and predict that an estimated 44% of American children will develop dental disease before 5 years of age (National Children’s Oral Health Foundation, 2009). These studies clearly illustrate the direct influence of income on oral health outcomes in the pediatric population. Oral hygiene practice
Oral hygiene practice should include daily flossing and brushing with fluoridated tooth paste, establishing a dental home, and regular visits to the dentist (Silk & Romano-Clarke, 2009). However, many children and adolescents lack access to a dentist and essential oral hygiene products (Federal Provincial and Territorial Dental Working Group, 2012). Oral health attitudes, knowledge, and skills have been associated with oral hygiene status (Ericsson, Ostberg, Wennstrom, & Abrahamsson, 2012). Specifically, higher levels of plaque and gingivitis were significantly related to a lack of knowledge and less positive beliefs and perceptions of oral health. Infrequent tooth brushing, recent fillings/extractions, dental plaque, and irregular visits to the dentist all increase the risk of early childhood caries (Dental Journal for Specialists in Pediatric Nursing 20 (2015) 105–114 © 2015, Wiley Periodicals, Inc.
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Nutritional intake. Dental disease, such as dental erosion, caries, and periodontal disease, has been linked to diet (Dental Health Promotion Working Group of Saskatchewan: Data, Evaluation, and Research Task Group, 2011; Marrs et al., 2011; Perera & Ekanayake, 2010). The Canadian Dental Association (2012b) reported that the consumption of food frequently, over time, and that are low in nutritional value and high in carbohydrates, as well as sugary drinks such as fruit juices, energy drinks, and carbonated beverages, can cause significant caries and erosion to tooth enamel. Other researchers found that frequent consumption of surgery drinks (carbonated, sport, and energy drinks) and snacks led to sustained acid production, increased breakdown of tooth layers, dental caries, and significant long-term enamel dissolution (American Academy of Pediatrics, 2011; Silk & Romano-Clarke, 2009). These findings support the relationship between nutritional intake and oral health and provide direction regarding the need for a careful nutritional history and provision of adequate health education about nutrition.
indicated that an infective and inflammatory disease, such as periodontitis, can have significant health effects on individuals with diabetes due to their altered immune and healing ability. In a sample of adolescents with DM1, Orlando and colleagues (2010) found that less than half were aware that periodontal disease was associated with diabetes. Plaque and gingival indices as well as the saliva mutans streptococci count have been found to be significantly higher in diabetic children (ages 5–18 years) than in healthy children; no statistical difference was found among well, fairly, and poorly controlled diabetic children regarding caries experience, salivary microorganisms, plaque, and gingival indices (El-Tekeya, Tantawi, Fetouh, Mowafy, & Khedr, 2012). In spite of this evidence, the focus of diabetes management has been on screening for all complications except periodontal disease (Gillis, 2010). Oral health screening for diabetes can lead to early detection and prevention of complications. However, diabetes screening through an oral health exam has also been overlooked in pediatric nursing (Percy, 2008). Opportunistic infections such as oral candidiasis can present as a sign of systemic immunosuppression, which can be attributed to diabetes mellitus type 2 (DM2; Ship, 2003). Given the recent increase in prevalence of DM2 in the pediatric population, early detection is critical to glycemic control and to reduce long-term complications of this disease (Percy, 2008; Sellers, Panagiotopoulos, & Lawson, 2008; Ship, 2003).
Diabetes
Risk behaviors
Prevalence rates of diabetes mellitus are increasing among children and adolescents (Dyck, Osgood, Lin, Gao, & Stang, 2010). Over a decade ago, periodontal disease was coined the sixth complication of diabetes (Loe, 1993). Today, this disease remains a serious threat to the oral health of individuals. Current results suggest that type 1 diabetes mellitus (DM1) plays a significant role in dentition and oral health in children and adolescents (Orbak, Simsek, Orbak, Kavrut, & Colak, 2008). For example, Saes Busato, Bittencourt, Machado, Gregio, and Azevedo-Alanis (2010) investigated the association between metabolic control and oral health in adolescents aged 14–19 years who have DM1 and reported that the oral health of all adolescents with DM1 was impaired (with respect to the presence of oral lesions, caries experience, periodontal conditions, and salivary control rates). Similarly, Gillis (2010)
A number of risk behaviors influence the oral health of adolescents, but these risks can also be seen in younger children. These behaviors include tobacco, alcohol and drug use, oral piercings, and certain sexual activities. Heikkinen and colleagues (2012) found teenage smokers to be at higher risk for early development of periodontitis and, generally, poorer overall oral health than nonsmokers. Other authors concluded that tobacco, including smokeless tobacco, can cause oral cancer, tooth staining, and gum disease (Silk & Romano-Clarke, 2009). One potential reason for the increased risk in using smokeless tobacco is the significantly higher levels of nicotine compared with cigarettes (Percy, 2008). An oral health program in an urban Canadian city reported that adolescents who chewed tobacco had a 50% increased risk of oral cancer (Public Health-Oral Health Program, 2009b). Tobacco use
Health Promotion Working Group of Saskatchewan: Data, Evaluation, and Research Task Group, 2011; Marrs, Trumbley, & Malik, 2011). In a large quantitative study conducted with adolescents ages 12–18 years, adolescents from affluent families were at lower risk for poor oral hygiene behaviors, such as erratic brushing and irregular visits to the dentist (Park, Patton, & Kim, 2010).
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was directly linked with oral cancer, making early diagnosis and treatment essential to reduce the impact of the disease (Federal Provincial and Territorial Dental Working Group, 2012). Although prevalence rates for alcohol and marijuana use have declined in adolescent populations in recent years (Health Canada, 2012), alcohol use leads to other oral health complications such as soft tissue abnormalities, gingival inflammation, and significant levels of dental caries. Frequent use of alcohol dries out the oral cavity, discolors teeth, and erodes tooth enamel (Public Health-Oral Health Program, 2009b). Drugs such as ecstasy, cocaine, methamphetamine, and marijuana have been linked to periodontal and lip disease, bruxism, severe tooth erosions, gingivitis, and premature tooth loss (Silk & Romano-Clarke, 2009). Oral piercing is another significant factor influencing the oral health of adolescents. This fashion trend for many adolescents has led to an increased risk for oral infections and trauma to the mouth (Silk & Romano-Clarke, 2009). The skin and mucous membranes provide a natural barrier to many infections, and an oral piercing can have serious health consequences, including contraction of diseases such as hepatitis B and C, HIV, tooth chipping or cracking, cyst formation, speech impediments, and damage to gums and other soft tissues in the mouth (Public Health-Oral Health Program, 2009a). Furthermore, the increasing prevalence of oral sex in adolescents is contributing to an overall rise in sexually transmitted infections (STIs) that can be transmitted orally, including HIV, human papillomavirus, herpes simplex virus, chlamydia, gonorrhea, and syphilis (Percy, 2008). A recent American study investigating racial/ethnic differences in prevalence and patterns of oral sex found African American girls were significantly less likely to engage in oral sex than White or Hispanic girls, and that an oral sex history was associated with a six-factor increase in STI (Auslander, Biro, Succop, Short, & Rosenthal, 2009). These authors concluded that sexually experienced girls who engaged in oral sex were likely to engage in other risk behaviors and had greater rates of STIs. Thus, a significant body of research provides evidence to support an approach to pediatric nursing practice that includes oral health care as an essential component of overall health and wellness. While studies have examined the factors influencing pediatric oral health, few published articles have explored collaborations between nursing and dentistry to address this current pediatric health problem. 108
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THE CARING FOR KIDS WHERE THEY LIVE PROGRAM
The nursing faculty at University of Saskatchewan, Canada established an educational approach based on an interprofessional pediatric clinical learning experience titled Caring for Kids Where They Live (Ogenchuk, Spurr, & Bally, 2014). The Bachelor of Science in Nursing (BSN) program discussed in this article is a 3 + 1 year baccalaureate program. All pediatric clinical experiences are offered in the third year of the BSN program. The primary objectives of this partnership were to support an interprofessional clinical experience and to promote wellness in the physical, psychological, spiritual, and social dimensions of children’s and adolescents’ lives. This initiative was designed to develop a holistic approach to pediatric care (Spurr, 2009; Spurr, Bally, Ogenchuk, & Peternelj-Taylor, 2011). Throughout the school year, third-year nursing students along with a designated nursing faculty member were placed in school settings for a total of 78 hr over a varied time period. During the clinical learning experience, every student received teaching from a dentistry faculty member or public health oral health hygienist on concepts and procedures related to pediatric oral health care. The nursing students conducted comprehensive oral assessments through observation and discussion, and made referrals as appropriate. The program included several members of the health professions (nurses, dentists, and physicians) and teachers, support staff, and administrators in the school system. This learning environment involved a group of seven nursing students being placed in one of three designated urban schools (one elementary and two secondary) to complete their pediatric clinical experience. Each year, approximately three to four groups of nursing students are placed in each of the schools. The elementary school is comprised of students aged 5–13 years and the high school students are approximately 14–19 years old. The schools selected for the three pediatric clinical placements enroll students from core, inner city neighborhoods in an urban midwestern Canadian city. Lemstra, Neudorf, and Opondo (2006) remark that the magnitude of poor health outcomes in these communities is shocking for a city in a western nation. Specific to oral health, children from these core areas are less likely to be cavity-free (34.1%) than children attending schools from other neighborhoods (59.8%; Neudorf et al., 2012). Journal for Specialists in Pediatric Nursing 20 (2015) 105–114 © 2015, Wiley Periodicals, Inc.
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Procedures and ethical considerations for the oral health clinical experiences
Planning for the oral health experiences includes working with the school administration to prepare a list of school students who will be assessed in the oral health clinic. At the start of the academic year, all parents are informed in a school newsletter of the purpose and proposed activities of the Caring for Kids Where They Live program. In the elementary school, consents are signed by parents before students are seen by oral health professionals. For the high school students, parents are asked to contact the principal at the school if they do not support the participation of their son/daughter in this program. Consent is implied if the school does not hear from the parent/guardian. In addition, the nursing faculty is available to meet with parents who may have concerns or questions. Traditionally, ninth grade and kindergarten students have been chosen first for the assessments, as they are new to that school’s environment. Students in grades 10–12 are then offered the opportunity to attend the oral health clinics. However, any student in the participating schools can request to access the Caring for Kids Where They Live program at any time while the nursing students are present. The health clinics are held in a private room in the school. Prior to starting the assessment, the nursing students work to establish a safe and trusting environment for the school students; this includes a detailed explanation of the purpose of the clinic and the role of the nurses in the school. After this initial discussion, the school students are reminded that their participation in the program is optional and are advised to answer only the questions with which they are comfortable. School students are informed that all interactions during the clinic are confidential, except if there is evidence of or potential for selfharm and/or causing harm to someone else. Upon this disclosure, the nursing student and supervisor are required to report the information to the school administrators and counsellor. In addition, there is a chance that some of the questions could make the students feel uncomfortable. Students are told that they do not have to answer any question they are uncomfortable with or that they do not wish to answer. If a student does experience discomfort, they can contact the nursing supervisor at the school and arrangements can be made with the school counselor to follow up. All parents and school students are notified of their right to refuse to participate in the program. Refusal to participate has no Journal for Specialists in Pediatric Nursing 20 (2015) 105–114 © 2015, Wiley Periodicals, Inc.
bearing on the students’ academic standing in any way. All case files are stored in a locked cabinet in the school and are destroyed upon graduation or when the student no longer attends the school. Only the principal and nursing supervisor can access the case files. Oral health assessment and teaching
The oral health assessment of the school students is uniquely designed to consider all previously identified factors influencing oral health of children and adolescents, and extends significantly beyond oral hygiene and caries. The assessment begins with a developmentally appropriate health history that investigates a given student’s family history and personal experiences with diabetes, heart disease, cancer, or other medical challenges. In the case of an adolescent client (ages 12–19 years), risk behaviors are explored and include questions such as oral piercings, smoking, chewing tobacco products, drugs, alcohol, and sexual activity (specifically oral sex). The nursing student completes the history with questions related to dental hygiene. Examples include: Do you have dental coverage? When did you last see your dentist? Do you brush? How often? Do you floss your teeth? The oral health physical assessment conducted is age appropriate (Figure 1). The extraoral component includes a thorough examination for swelling, symmetry, and bruising. The intraoral assessment involves counting all teeth, assessing for holes or dark staining on biting surfaces, checking cheeks and tongue sides of teeth, and looking at the gums to identify the presence of bleeding, redness, and gum recession. The assessment also requires observing for bumps and lumps in the mouth, including the tongue, gums, and inner cheeks. This is done because the most frequent form of oral precancerous lesions (leukoplakia) appear as a white patch that cannot be rubbed off, and these generally appear in the buccal mucosa, lateral borders of the tongue, and floor of the mouth (Bratthall, Petersen, Stjernsward, & Brown, 2006). A final step includes noting fillings, previous dental work, appliances, and braces. Oral health teaching is completed immediately following the assessment and includes proper technique for brushing and flossing teeth, nutrition, and the provision of information related to establishing or maintaining a dental home. All students are also provided with appropriate health education resources and a new toothbrush. A more detailed assessment and teaching is provided for any student 109
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Caring for Kids Where They Live: Oral Health Assessment Guide Student Name:
Reference Priority: 1 2 3
Age:
Medical History: Allergies, Heart disease, Diabetes, Arthritis, and other medical problems. Health Behaviours: Drugs, Smoking, Chewing Tobacco, Alcohol, Oral Piercing, Oral Sex Do you have any oral piercings? Are you sexually active, and if so, are you having oral sex? Are you protecting yourself against sexually transmitted infections? Do you have any questions about birth control or sexually transmitted infections? In the past 12 months, how many cigarettes did you usually smoke per day? In the past 12 months, did you chew tobacco? In the past 12 months, how often did you drink alcohol (beer, wine, coolers, or hard liquor)? In the past 12 months, how often did you use cannabis? In the past 12 months, have you used inhalants to get high, or use cocaine, crack cocaine, crystal meth, tranquilizers, LSD, or amphetamines?
Dental Hygiene History When was your last dental visit? Who and where is your dentist? Do you have dental coverage? Do you brush your teeth? How often? Do you floss your teeth? How often? Do your teeth hurt? How often? When? Where? Do your teeth hurt when you drink something cold or hot?
Oral Health Physical Assessment Extra Oral: Assess face for symmetry, swelling, and bruising.
Intra Oral:
Figure 1 Caring for Kids Where They Live: Oral Health Assessment Guide. Note: Permission was granted for this adapted version from Dr. A. Koneru who was an Assistant Professor in Pediatric Dentistry at the University of Saskatchewan. LSD, lysergic acid diethylamide.
Count teeth (including if any wisdom teeth are present) and record if some teeth are missing. Record teeth with decay or any teeth that may have decay. Assess for any holes, dark staining on biting surfaces, cheek, and tongue side of teeth. Assess gums for bleeding, redness, and gum recession. Assess in mouth for any bumps or lumps, and sores. Assess tongue and lips (record any piercings). Pull cheeks away from teeth and assess inner cheeks and teeth. Note any fillings or any previous dental work. Note any braces or appliances.
Additional Notes from Assessment
Teachings, Recommendations, and Plan
Signature:
Date:
who identifies high-risk behaviors. If appropriate, the nursing students work with the school student to set realistic and individualized goals. Throughout the school year, the nursing students continue to follow these particular clients, including further assessment and intervention. General procedures for follow-up
After the nursing student completes the assessment, a dentist or dental therapist facilitates decisionmaking and follow-up procedures as needed. The school student is given a form to take home with the results of the assessment, and the nursing students record the assessment on another form that is kept at the school. As illustrated in Figure 2, each school student is assigned a reference number of one, two, or three, which provides a process for prioritizing 110
any follow-ups and referrals required. A number one signifies that the student has urgent oral health needs, and intervention is required in the immediate days following the clinic. A number two indicates that the school student has dental problems and should be followed in the future. A number three signifies that the student is being followed by, and has seen, a dentist in the last year and has no dental problems at the time of the assessment. Outcomes of the Caring for Kids Where They Live program
Since its inception, the Caring for Kids Where They Live program has experienced many successful outcomes. The number of school students assessed and the number of referrals vary by year and by school. In general, a group of seven nursing students can Journal for Specialists in Pediatric Nursing 20 (2015) 105–114 © 2015, Wiley Periodicals, Inc.
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High School
Number of School Students
60 Cases Requiring Urgent Dental Care
50 40 30 20
Cases Requiring Urgent Dental Care
10 0
Completed Oral Health Assessments
Completed Oral Health Assessments
Figure 2 Oral Health Assessments in Elementary and High School Students.
assess 35 school students during a 78-hr clinical experience and are required to follow up with at least one health issue for approximately 50–60% of these students. Outcomes of the school experiences are demonstrated in Figure 1. The follow-up for the school students can simply be a discussion about smoking cessation or checking to see if the student or parent/guardian made an appointment with the dentist. However, the nursing care that is required can also be extremely complex and urgent in nature. For example, one client requiring urgent oral health care had braces placed in his mouth in his home country 18 months prior to the student nurse assessment. The adolescent male had been living in Canada for over a year and, due to finances, had not yet visited an orthodontist. The nursing students immediately attempted to advocate for and intervene on behalf of this adolescent client by calling five local orthodontists who all refused to take the case due to insurance-related reasons. The dentist who had been volunteering from the local university was then contacted and was able to make arrangements for the client to be assessed by a university orthodontist. Regular appointments for assessment and revision of the adolescent’s braces were established along with affordable payments for the family. After the client had his first appointment, he came to thank the nursing students, saying “thank you, thank you, thank you. Now my mom does not have to cry every day because I have my braces on.” This heartfelt expression provided evidence of the difference that the Caring for Kids Where They Live program had made for this adolescent and his family. Journal for Specialists in Pediatric Nursing 20 (2015) 105–114 © 2015, Wiley Periodicals, Inc.
In another example, an oral assessment completed with a 6-year-old male student resulted in appropriate referral and treatment. The initial assessment included a visual examination of the child’s teeth. The nursing students identified that the young boy had one decayed tooth, two missing teeth, and seven capped teeth. The elementary school student was asked about his diet, oral health habits, and when he last saw a dentist. Although he did not recall when he visited the dentist, it was obvious that he had received previous care. A review of brushing techniques and flossing were provided because of the obvious tartar and plaque along his gum lines. He was also reminded to limit sugary treats and brush at least once a day, preferably before bed. The parents were notified about the new decay, which resulted in another cap on one of the teeth by the family dentist. This example demonstrates successful collaboration between the family and nursing students, and an opportunity for advocacy by the nursing students. Referrals
Another important component of the Caring for Kids Where They Live program was the development of methods for referrals to dentistry and orthodontists. Nursing students were able to work effectively with the school administration, families, and dentists to overcome barriers, including consent, finances, and transportation. For example, contact was initiated and information was provided to facilitate parental consent in order to proceed with necessary referrals. Ultimately, effective partnerships and pathways were developed to ensure follow-up care was provided to those children, adolescents, and families who were identified as requiring referrals. NURSING RESEARCH IMPLICATIONS
Future nursing research should explore which strategies might be most effective in teaching nurses to successfully incorporate oral health care into their nursing practice. Research should be conducted to include children of all ages and backgrounds, and in a variety of geographical areas, because these considerations play a significant role in the complex issues related to pediatric oral health. Pediatric nurses are leaders in pediatric health and well-being and, therefore, are strategically positioned to lead and conduct interprofessional, scientific research that will guide policy and improve holistic and 111
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comprehensive pediatric nursing care. This has the potential to significantly contribute to enhanced pediatric nursing care and broadly enhance oral health care and overall public health in pediatrics. CONCLUSION
Oral health has long been identified as an essential component of pediatric health. There is myriad evidence regarding the factors influencing oral health and the serious health effects of pediatric dental disease. Despite the identified importance of oral health, the focus of the literature and pediatric nursing practice has remained centered on medical problems, including common childhood illnesses. The Caring for Kids Where They Live program is an example of a collaboration that has successfully integrated oral health into pediatric nursing care. Evidence of positive outcomes includes accessibility of health care, establishing pathways for care, and oral health disease prevention, resulting in improved oral health and overall wellness for children and adolescents in school settings. Given the positive outcomes of the collaborative program, nurses are encouraged to support an approach to pediatric nursing practice that includes oral health care. Nurses should ensure that their clinical practice skills include the ability to advocate for and integrate oral health assessments, fluoride treatments, followup, and referrals into all pediatric care settings.
How might this information affect nursing practice?
Pediatric oral health is important and can impact quality of life for children and adolescents. Lowincome status, diabetes, oral hygiene, and other risk factors, particularly in adolescents, such as smoking, using smokeless tobacco, oral piercing, drug and alcohol use, and unsafe oral health practices, influence the burden of pediatric oral disease. Despite this knowledge, nurses in practice tend to focus on other medical problems and often overlook the oral health needs of children. In addition, there are few evidence-based guidelines for nurses who wish to address this prevalent pediatric chronic disease. Progress to improve the dismal pediatric oral health statistics in the twenty-first century will require nurses to recognize the importance of an integrated collaborative approach that is based on empirical research. The Caring for Kids Where They Live program is an example of an
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interprofessional collaboration that has successfully integrated oral health. This program has resulted in improved overall oral health for school children, including increased access to oral health care and establishing pathways for care, prevention, and treatment. Nurses are strategically positioned to promote oral health by (a) addressing the complex sociocultural factors that continue to support oral health disparities within the pediatric population; (b) using an oral health assessment tool, follow-up, and referral processes in pediatric nursing practice; and (c) creating partnerships between nursing and dentistry that address the current solitary nature of the provision of oral health care. Implementing a collaborative approach to pediatric oral health care can be a means to improve the overall health and quality of life of children and adolescents.
References American Academy of Pediatrics. (2011). Sports drinks and energy drinks for children and adolescents: Are they appropriate? Retrieved February 4, 2015, from http://pediatrics.aappublications.org/content/127/6/ 1182.full Auslander, B. A., Biro, F. M., Succop, P. A., Short, M. B., & Rosenthal, S. L. (2009). Racial/ethnic differences in patterns of sexual behavior and STI risk among sexually experienced adolescent girls. Journal of Pediatric and Adolescent Gynecology, 22(1), 33–39. Blevins, J. Y. (2011). Oral health care for hospitalized children. Pediatric Nursing, 37(5), 229–235, quiz 236. Bratthall, D., Petersen, P. E., Stjernsward, J. R., & Brown, L. J. (2006). Oral and craniofacial diseases and disorders. In A. D. Lopez, C. D. Mathers, M. Ezzati, D. T. Jamison, & C. J. Murray (Eds.), Disease control priorities in developing countries (2nd ed., pp. 723–736). Washington, DC: World Bank. Canadian Dental Association. (2012a). Access to oral health care for Canadians. Retrieved February 4, 2015, from http://www.cda-adc.ca/_files/position_statements/ accessToCarePaper.pdf Canadian Dental Association. (2012b). Junk food. Retrieved February 4, 2015, from http://www.cda-adc.ca/_files/ position_statements/junkFoodAndChildHealth.pdf Canadian Dental Association. (2012c). Oral health—good for life. Retrieved September 1, 2014, from http://www.cda -adc.ca/en/oral_health/cfyt/good_for_life/ Dental Health Promotion Working Group of Saskatchewan: Data, Evaluation, and Research Task Group. (2011). Spot light on oral health—special double
Journal for Specialists in Pediatric Nursing 20 (2015) 105–114 © 2015, Wiley Periodicals, Inc.
S. Spurr et al.
Integrating Oral Health into Pediatric Nursing Practice: Caring for Kids Where They Live
digest. Retrieved October 1, 2014, from http://www.sdta.ca/mrws/filedriver/Spring_Spotlight _DHPWG_OF_SK.pdf Dyck, R., Osgood, N., Lin, T. H., Gao, A., & Stang, M. R. (2010). Epidemiology of diabetes mellitus among first nations and non-first nations adults. Canadian Medical Association Journal, 182(3), 249–256. El-Tekeya, M., Tantawi, M., Fetouh, H., Mowafy, E., & Khedr, N. (2012). Caries risk indicators in children with type 1 diabetes mellitus in relation to metabolic control. Pediatric Dentistry, 34(7), 510–516. Ericsson, J. S., Ostberg, A. L., Wennstrom, J. L., & Abrahamsson, K. H. (2012). Oral health-related perceptions, attitudes, and behavior in relation to oral hygiene conditions in an adolescent population. European Journal of Oral Sciences, 120, 335–341. Federal Provincial and Territorial Dental Working Group. (2012). Canadian oral health framework: 2013–2018. Retrieved February 4, 2015, from http://www.caphd .ca/sites/default/files/FrameworkOctober%202014%20 -%20FINAL%20English.pdf Gillis, A., & Mac Lellan, M. (2010). Service learning with vulnerable populations: Review of the literature. International Journal of Nursing Education Scholarship, 7(1), 1–27. Gillis, M. R. (2010). A place for oral health in diabetes management. Journal of the Canadian Dental Association, 76(a24), 1–3. Health Canada. (2012). Youth smoking survey 2010–11 data tables. Retrieved September 17, 2014, from http://www.yss.uwaterloo.ca/results/YSS2010-2011 _supplementary_tables_en.pdf Heikkinen, A., Pitkäniemi, J., Kari, K., Pajukanta, R., Elonheimo, O., Koskenvuo, M., & Meurman, J. H. (2012). Effect of teenage smoking on the prevalence of periodontal bacteria. Clinical Oral Investigations, 16, 571–580. Iocopini, A. (2010). Models for interprofessional practice: Innovative collaboration between nursing and dentistry. Journal of the Canadian Dental Association, 76(a16). Lemstra, M., Neudorf, C., & Opondo, J. (2006). Health disparity by neighbourhood income. Canadian Journal of Public Health, 97(6), 435–439. Loe, H. (1993). Periodontal disease. The sixth complication of diabetes mellitus. Diabetes Care, 16(1), 329–334. Marrs, J. A., Trumbley, S., & Malik, G. (2011). Early childhood caries: Determining the risk factors and assessing the prevention strategies for nursing intervention. Pediatric Nursing, 37(1), 9–15, quiz 16. National Center for Health Statistics. (2010). Health: United States 2009 with special feature on medical technology. Retrieved September 15, 2014, from http://www.cdc.gov/nchs/data/hus/hus09.pdf National Children’s Oral Health Foundation. (2009). America’s toothfairy: Because every child deserves a healthy
Journal for Specialists in Pediatric Nursing 20 (2015) 105–114 © 2015, Wiley Periodicals, Inc.
smile. Retrieved November 2, 2012, from http://www.ncohf.org/why Neudorf, C., Muhajarine, N., Marko, J., Murphy, L., Macqueen Smith, F., Clarke, A., . . . Wu, J. (2012). Healthy families plus healthy communities equals healthy children: A report of the chief medical health officer on the health status and development of young children in Saskatoon health region, 2012. Retrieved November 2, 2012, from https://www.saskatoonhealthregion.ca/locations _services/Services/Health-Observatory/Documents/ Reports-Publications/Healthy_Families_Full_Report _2012.pdf Ogenchuk, M., Spurr, S., & Bally, J. (2014). Caring for Kids Where They Live: Interprofessional collaboration in teaching and learning in school settings. Nurse Education in Practice, 14(3), 293–298. doi:10.1016/ j.nepr.2013.11.003 Orbak, R., Simsek, S., Orbak, Z., Kavrut, F., & Colak, M. (2008). The influence of type-1 diabetes mellitus on dentition and oral health in children and adolescents. Yonsei Medical Journal, 49(3), 357–365. Orlando, V. A., Johnson, L. R., Wilson, A. R., Maahs, D. M., Wadhwa, R. P., Bishop, F. K., & Morrato, E. H. (2010). Oral health knowledge and behaviors among adolescents with type 1 diabetes. International Journal of Dentistry, 2010, 1–8. doi:10.1155/2010/942124 Park, Y. D., Patton, L. L., & Kim, H. Y. (2010). Clustering of oral and general health risk behaviors in Korean adolescents: A national representative sample. Journal of Adolescent Health, 47(3), 277–281. Percy, M. S. (2008). Oral health of adolescents–it’s more than dental caries. American Journal of Maternal Child Nursing, 33(1), 26–31. Perera, I., & Ekanayake, L. (2010). Relationship between dietary patterns and dental caries in Sri Lankan adolescents. Oral Health & Preventive Dentistry, 8(2), 165–172. Petersen, P. E. (2009). Global policy for improvement of oral health in the 21st century—implications to oral health research of World Health Assembly 2007, World Health Organization. Community Dentistry and Oral Epidemiology, 37, 1–8. Polk, D. E., Weyant, R. J., & Manz, M. C. (2010). Socioeconomic factors in adolescents’ oral health: Are they mediated by oral hygiene behaviors or preventive interventions? Community Dentistry and Oral Epidemiology, 38(1), 1–9. Public Health-Oral Health Program. (2009a). The piercing truth. Retrieved November 6, 2012, from https://www.saskatoonhealthregion.ca/locations _services/Services/Oral-Health/Documents/What%20 you%20Need%20to%20Know%20about%20Oral%20 Piercing.pdf Public Health-Oral Health Program. (2009b). Tooth tips for teens. Retrieved November 6, 2013, from
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https://www.saskatoonhealthregion.ca/locations _services/Services/Oral-Health/Documents/Tooth%20 Tips%20for%20Teens.pdf Saes Busato, I. M., Bittencourt, M. S., Machado, M. A., Gregio, A. M., & Azevedo-Alanis, L. R. (2010). Association between metabolic control and oral health in adolescents with type 1 diabetes mellitus. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics, 109(3), e51–e56. Sellers, E., Panagiotopoulos, C., & Lawson, M. (2008). Type 2 diabetes in children and adolescents. Canadian Journal of Diabetes, 32(Suppl. 1), S162–S167. Ship, J. (2003). Diabetes and oral health: An overview. Journal of the American Dental Association, 134(October), 4S–10S. Silk, H., & Romano-Clarke, G. (2009). The seven tenets to teen oral health. Contemporary Pediatrics, 26(6), 50–59.
114
S. Spurr et al.
Spurr, S. (2009). Student perceptions of adolescent wellness. Doctoral Dissertation. Retrieved March 1, 2014, from http://library2.usask.ca/theses/available/ etd-07212009-140354/ Spurr, S., Bally, J., Ogenchuk, M., & Peternelj-Taylor, C. (2011). A wellness framework for pediatric nursing clinical practice. Holistic Nursing Practice, 25(6), 298–308. Telford, C., Coulter, I., & Murray, L. (2011). Exploring socioeconomic disparities in self-reported oral health among adolescents in California. Journal of the American Dental Association, 142(1), 70–78. World Health Organization. (2012). Media centre: Oral health. Fact sheet #318. Retrieved September 14, 2014, from http://www.who.int/mediacentre/factsheets/ fs318/en/
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