Adolescents live in a world of contradictions; a world that offers endless opportunities and at the same time presents possibilities for risk-taking behaviors, many of which can have an adverse effect on adolescent oral health.1,2,3 Thus, it seems essential for dentists who treat adolescent patients to not only possess the requisite knowledge and technical skills for successful dental management, but perhaps more importantly to enhance their understanding of today’s adolescent. The goal of this article is to provide practicing dentists with background information regarding the adolescent phase of development in order to facilitate successful dental management and improve the oral health of their adolescent patients.
The Adolescent Patient
Considering the vast amount of information available currently related to the topic of adolescence, it may be surprising to note that adolescence was not even identified as a distinct life stage until the turn of the 20th Century. While there is no standard definition for adolescence, it is generally regarded as the transition period between childhood and adulthood, chronologically ranging from 10 to 18 years of age. Recent publications have suggested that some adolescents, who traditionally would be entering the adulthood phase at around 19 years of age, nowadays are likely to experience a delay in accomplishing this transition based on current social and economic conditions.4 This new phase has become known as the emerging adult, and has resulted in a delay in achieving the traditional milestones of progressing through the transition from adolescence to adulthood that includes completing school, leaving home, establishing financial independence, identifying a partner, and starting a family.4
Adolescence is a period of profound change — the tumultuous teens! Physical growth and development progress to completion, including the hormonal alterations accompanying sexual maturity. The struggle for social integration is in tension with establishing independence from parents versus succumbing to peer pressure, and the opportunities to engage in high risk behaviors are all too familiar. The adolescent brain progresses through developmental and functional changes that contribute to higher thought levels and motor skill refinement such as hand-eye coordination. In addition, the adolescent brain undergoes a pruning process in which skills that are practiced during this crucial developmental period are enhanced, while those that are ignored become diminished.5
Thus as practitioners we need to recognize and respond appropriately to the many behavioral variations exhibited by adolescents as a group and even within the same individual adolescent. This range of variability may extend from the positive for those adolescents who are health conscious, achievement oriented, and appearance focused, to those exhibiting negative, unpredictable, risk-taking, or anti-social behaviors.
As adults dealing with adolescents and as dentists treating adolescent patients, we enter this world of profound change, perhaps with the next patient awaiting our entrance into the dental operatory.
Adolescent Informed Consent and Confidentiality
Along with those developmental aspects encountered during the adolescent period as described in the preceding section, the issues of adolescent informed consent and confidentiality also are of critical importance in dental practice management during this period of transition.6, 7, 8 The following information is not intended as legal advice, but rather as an impetus to initiate discussion between the practitioner and legal counsel, as laws and customary practices may vary among jurisdictions.
As with all patients, it is essential to begin by building a trusting relationship between the dentist and the adolescent patient. The foundation for this trust-building process is based in large part on honest, detailed information garnered from a thorough medical and dental history, which by necessity contains questions of a sensitive nature.6 The dentist must be aware of risky behaviors and activities that can affect the oral as well as the general health of the adolescent patient. Included within this context should be questions about dietary habits, use of alcohol, tobacco, and other substances such as prescription medications or recreational drugs, and sexual activity.
This confidential information is subject to the standards set by federal mandate in the Health Insurance Portability and Accountability Act, as well as the legal age of consent established by the local jurisdiction.6 In many states, the legal age of majority, with some exceptions, is 18 years of age.6, 7, 8 Many adolescent dental patients have yet to reach this milestone. Thus, questions for the dentist to consider are how much of this confidential information could/should be shared with the parents or legal guardians, and who must provide the informed consent for treatment of the non-emancipated adolescent?
As the health care provider, the dentist should discuss the possibility of likely disclosures with the adolescent patient and with the parents or legal guardians.6 For example, the insurance coverage documents that might include disclosure of some confidential information are sent to the insured, most likely a parent or legal guardian. In addition, disclosure of other confidential information may be required to obtain adequate informed consent for adolescent patients who have yet to reach the age of majority. This is best accomplished with candid, trusting discussion. Some adolescent patients may prefer minimum disclosure; so each practitioner must establish personal comfort levels with requested disclosure limitations and then determine whether or not to treat or decline treatment of the adolescent patient under those circumstances. 6
Adolescent Risk-Taking Behaviors Affecting Oral Health
How best to engage the adolescent in promoting oral health related to selected risk-taking behaviors is the subject of the remainder of this article. Topics will be limited to adolescent obesity, use of tobacco products, and sexually transmitted diseases.
The prevalence of overweight and obesity has reached epidemic levels among U.S. youth, affecting approximately 32% of all children and adolescents. Compared to data from the early 1970s, the prevalence of overweight nearly quadrupled among U.S. children between 6 and 11 years of age, and nearly tripled among those 12 to 17 years old. The Surgeon General has suggested that in the near future, obesity-related health care costs may surpass those related to cigarette smoking. 9
Several characteristics present in today’s society have contributed to youth becoming overweight or obese. These include sedentary lifestyles, excessive consumption of soda and juice, larger sized portions of food served over the past decade, fewer meals eaten together as a family, and consumption of fewer fruits and vegetables. National surveys also have reported that U.S. youth aged 8 to 16 years are involved in only two hours or less of physical activity per week. Minority youth are more likely to become overweight than their non-Hispanic Caucasian counterparts, and those from low socioeconomic backgrounds are especially at risk for becoming overweight. 9
The negative medical implications of overweight/obesity have been well documented, and include an increased likelihood for health problems that have immediate consequences as well as long-term health implications. Some of these manifestations include hypertension, glucose intolerance, sleep apnea, hyperlipidemia, and elevated levels of liver enzymes associated with fatty liver. Childhood type II diabetes accounts for approximately 45% of all newly diagnosed cases of diabetes mellitus in the U.S. Most importantly, obese adults have an increased risk of early death when compared to individuals who have a healthy weight range.9, 10, 11
Dental consequences also have been associated with overweight/obesity, including accelerated dental growth and development. One study of 7- to 15-year-old youth using calculated Body Mass Index (BMI) and evaluation of dental ages from panoramic radiographs revealed that dental development was accelerated significantly with increased BMI, even after adjusting for age and gender.10 This accelerated dental growth and development is of particular importance as it may affect orthodontic treatment timing options, serial extractions, and space maintenance in the developing dentition.
An increased BMI and adiposity may present a significant challenge to dentists or anesthesiologists attempting to sedate adolescent patients for dental care, such as those requiring surgical extraction of third molars. These problems may include respiratory complications, in particular the increased likelihood for aspiration; cardiovascular complications; difficulty in achieving the level and duration of sedation desired; and longer recovery time. 9
The associations between overweight/obesity and dental caries have yet to be determined definitively.11, 12 The National Health and Nutrition Examination Survey examined the relationship between age-specific BMI and dental caries in primary and permanent dentitions of 2- to 17-year-olds. No significant association between BMI-for-age and dental caries prevalence in either dentition was documented. Given the link the between refined carbohydrate consumption and dental caries, as well as the link between dietary intake of refined carbohydrates and being overweight, it is somewhat surprising that being overweight was not associated with increased prevalence of dental caries in either dentition. Findings from this study indicated that more research needs to be conducted to address what specific factors in overweight youth may be protective against dental caries and that the association between weight and dental caries is complex and multifactorial.11
Dentists who treat children and adolescents are in a unique position to implement protocols and to monitor their patients who are overweight or obese. Because of the frequent dental recall intervals that occur over time, the dentist has the opportunity for longitudinal counseling and monitoring of weight status. Dentists can utilize dental visits to augment screening and counseling that will complement the physician’s efforts in addressing overweight/obesity. Anticipatory guidance protocols should include discussions of appropriate dietary habits and the medical and dental consequences of overweight/obesity. The dental team needs to measure and record height, weight, and BMI percentiles at each dental recall examination. This information should provide the dentist, the parents, and the patient with longitudinal data regarding growth and development. Referrals to the physician and/or dietician should be made as indicated. Coordination and cooperation between primary health care providers is necessary if a reduction in the incidence of obesity in the U.S. is to occur.
A recent study of 2,965 American Dental Association members indicated that more than one-half of the respondents were interested in offering obesity-related services, but fewer than five percent currently were offering these services. The barriers to providing these services included concern about offending patients or appearing to be too judgmental. A smaller percentage of respondents believed that they were not trained adequately and that the patients might reject their weight loss advice. The dentists stated that they were more likely to intervene if obesity were linked definitively to oral disease.13
Childhood overweight/obesity is increasing at exponential rates and requires collaboration from all primary health care professionals. Continuing education programs as well as dental curricula should be revised to reflect current clinical and evidence-based information on this important subject.13 Dentists have the opportunity to intervene and engage in screening for overweight/obesity and to offer appropriate counseling and referral.
Adolescent Tobacco Use
The long-term adverse effects of cigarette smoking on multiple organ systems are well documented and continue to represent the single leading preventable cause of death and disease in the United States.14 Included among this litany are lung diseases such as chronic bronchitis, emphysema, chronic obstructive pulmonary disease, and lung cancer; cardiovascular diseases, high blood pressure, and myocardial infarction; reproductive disturbances such as impotence in males and pregnancy complications in females; harmful effects on bone density and higher risks for glucose intolerance and the development of diabetes; gastrointestinal disorders such as increased acid production and diverticulitis; interference with thyroid hormone production, increased liver scarring, and delayed wound healing, among others. Not only does this spectrum represent enormous morbidity and mortality, but also astronomical economic impact.14, 15
Similar to the initiation of other risk taking behaviors, greater than 80% of habitual adult smokers began smoking cigarettes as adolescents before 18 years of age.15 One report indicated that in 2009, 5.2% of middle school students and 17.2% of high school students were self-reported cigarette smokers. For both groups, more males reported smoking than females. While these figures represent a general lack of significant change based on previous reports, there have been some declines that could be classified as relatively slow.14, 15
In addition to the deleterious systemic effects listed above, the oral hard and soft tissues are not immune from damage caused by cigarette smoking. Oral malodor and tobacco stained teeth are common. Adolescents who smoke experience impaired gingival health and delayed wound healing.16 This is especially important because adolescence is the usual time for surgical extraction of the third molars.17 In addition, adolescent young women who take birth control pills also may experience delayed healing at third molar extraction sites.18 Cigarette smoking is also a significant contributing factor for the development and subsequent devastation caused by oral, pharyngeal, and laryngeal carcinomas.
Education at all levels remains one key factor in reducing the initiation of cigarette smoking as well as the use of other tobacco products. For those who already are addicted to the effects of nicotine, members of the health care team including dental practitioners share the responsibility to provide the adolescent with an appropriate entrée to make a successful quit attempt and break the nicotine addiction. Behavioral and pharmacological interventions are available. Included among the pharmacological modalities are nicotine replacement patches, chewing gums, lozenges, inhalers, nasal sprays, and oral medications. However, it should be noted that the pharmacological data sheets indicate that insufficient safety and efficacy information has been established for recommending use of these products for those under18 years of age, so prescribing such modalities for adolescents may constitute off-label use.
Smokeless tobacco (ST), also referred to as spit tobacco, is another addictive form of tobacco used by some adolescents. ST is available as chewing tobacco (loose-leaf, plug, twist, and roll) or as snuff (dry, moist, and sachets).19 These products contain various concentrations of nicotine (one dip contains 3-5 times the nicotine as one cigarette); at least 28 carcinogens such as benzoprene, formaldehyde, and nitrosamines; and 3,000 other chemicals such as acetone, ammonia, and cadmium. Thus, the addictive properties of nicotine combined with the carcinogenic and chemical components of these products constitute a serious health threat to adolescents who frequently initiate ST use during this developmental period. Further, it should be noted that adolescents who already use ST are more likely to initiate cigarette smoking.15 It is important for the dentist to deliver an emphatic message that ST use is NOT a safe alternative to cigarette smoking.20
The reasons for initiating ST use vary among youth. In some instances it may be in response to peer pressure; in others to emulate an admired sports figure.20 This is sometimes the case with youth baseball players or those who participate in rodeo events. In addition, amateur wrestlers are prone to use ST in order to repress appetite and to decrease or maintain a specific weight classification. Regardless of the specific factors that led to the initiation of ST use, over time the nicotine dependence/addiction leads to increasing frequency of use to maintain the nicotine dose (the so-called “buzz”).20, 21, 22 This often leads to brand switching to ST products that contain higher nicotine levels with increased exposure impact on the individual user.20
In terms of usage and initiation rates for ST, an annual average of 3.2 percent of persons from 12 years of age and older in the United States (estimated at 7.8 million persons) reportedly had used ST during the preceding month; with initiation rates highest among adolescents and young adults.14, 15, 19, 20 Males overall were more frequent users of ST than females. Use of ST among middle school students overall was reported as 2.6% (4.1% males compared to 1.2% females); and among high school students overall it was 7.9% (13.4% males compared to 2.3% females).14, 15 These trends should prompt dentists to remain alert to the possibility of adolescent female ST users and to conduct a thorough history and oral cancer screening examination for adolescents regardless of gender.14,15,19,20
Other demographic and geographic factors reported that American Indians and Alaska natives were more likely than any other racial/ethnic groups to use ST, and that persons living in the rural South or Midwest were more likely ST users than those residing in urban West or Northeast regions of the US.14, 15, 19, 20
ST use has been shown to have deleterious effects not only on oral health, but also on systemic health similar to those described in the previous section related to smoking cigarettes. Deleterious oral manifestations associated with ST include oral malodor, stained teeth, dental caries (associated with the sugar content of ST), gingival irritation, gingival recession (Figure 1), alveolar bone loss, and tooth loss. Oral mucosal irritation related to the repeated placement of the ST in a specific area of the mouth may result in leukoplakia, a precancerous white patch that is not easily scraped off the surface of the oral tissue. In many instances the white patch will resolve following cessation of the ST habit (Figure 2). In other instances with increased use, the snuff dippers’ leukoplakia becomes thickened (Figure 3). The most severe and life-threatening damage associated with ST use follows a diagnosis of oral cancer with subsequent treatment combinations of surgery, chemotherapy, or radiation therapy.
Adolescent dental patients must be made aware of all of these devastating possibilities associated with ST use and to be advised against the initiation of such habits in the first place; or for those who already are addicted to initiate strategies that facilitate a successful quit attempt to improve the oral and general health of the adolescent patient.21, 22
Adolescent Sexual Activity
Information regarding the sexual activity of adolescent dental patients is essential for the practitioner to obtain through a detailed medical history and oral examination. The sensitive nature of this personal information needs to be conveyed to the adolescent in a non-judgmental manner, and the confidentiality issues described previously need to be established.6 Pertinent information includes the onset of puberty (menarche), the use of birth control pills, the possibility of teen pregnancy, and evidence of sexually transmitted diseases (STDs), including oral lesions.
According to the Centers for Disease Control and Prevention (CDC), in 2009, 46% of high school students reported ever having engaged in sexual intercourse, 14% had four or more lifetime partners, and 34% of sexually active high school students had not used a condom during their most recent encounter.23 In addition, in 2002, 55% of males and 54% of females aged 15 to 19 years old reportedly had engaged in oral sex with a partner of the opposite sex; and in that same year, 12% of all pregnancies (757,000) occurred among adolescents in the 15- to 19-year-old age range. In terms of STD, the CDC reported that each year there are approximately 19 million new STD infections, with nearly one-half occurring among adolescents and young adults between 15 to 24 years of age.23
In performing the oral examination, the dentist should be alert to the possibility of palatal soft tissue trauma (Figure 4) and herpetic lesions (HSV-2) among teenagers who engage in oral sex (Figure 5), as well as venereal warts and the possibility of oral cancer among sexually active adolescent patients. It is important to note that human papillomavirus (HPV), a sexually transmitted infection linked to cervical cancer, also has been linked to the pathogenesis of oropharyngeal squamous cell carcinomas transmitted to the mouth through oral sex. High risk HPV16 has been identified in the vast majority of HPV-positive tumors.24 It is alarming that patients with this subset of head and neck squamous cell carcinomas tend to be younger, non-smokers, and non-drinkers.
The importance of oral cancer screening for all patients including adolescent males and females cannot be overemphasized, as early diagnosis and treatment have significant prognostic implications.
Although the adolescent years may be difficult emotionally and contributory to a variety of risk-taking behaviors, this period of progressive transformation of the child into an adult also offers a unique gateway for dental practitioners to promote the development of positive health behaviors as the foundational basis for the future oral and general health and well-being of our current adolescent dental patients.
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4. Arnett JJ. Readings on Adolescence and Emerging Adulthood. Upper Saddle River (NJ): Pearson Education, 2001; page 293.
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15. Centers for Disease Control and Prevention. Youth and Tobacco Use. Available at: http://www.cdc.gov/tobacco/data_statistics/facts_sheets/youth_data/tobacco_use/index.htm
16. Heikkinen AM, Pajukanta R, Pitkaniemi J, Broms U, Sorsa T, Koskenvuo M, Meurma JH. The effects of smoking on periodontal health of 15- to 16-Year-Old Adolescents. J Periodontol 2008;79:2,042-2,047.
17. Sweet JB, Butler DP. The relationship of smoking to localized osteitis. J Oral Surg 1977 37(10):732-735.
18. Cohen ME, Simecek JW. Effects of gender-related factors on the incidence of localized osteitis. Oral Surg Oral Med Oral Path Oral Radiol Endo 1992;79:416-422.
19. Centers for Disease Control and Prevention: Smokeless Tobacco Facts. Available at: http://www.cdc.gov/tobacco/data_statistics/fact_sheets/smokeless/smokeless_facts/index.htm.
20. Centers for Disease Control and Prevention: Smokeless Tobacco: Impact on the Health of Our Nation’s Youth and Use in Major League Baseball. http://www.cdc.gov/washington/testimony/2010/t201000414.htm Accessed December 27, 2010.
21. Ranalli DN, Elderkin DL: Oral health issues for adolescent athletes. Dent Clin North Am 50(1):119-137, January, 2006.
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23. Centers for Disease Control and Prevention: Healthy Youth! Health Topics: Sexual Risk Behaviors. Available at: http://www.cdc.gov/healthyyouth/sexualbehaviors/index.htm .
24. Fakhry C, Gillison ML. Clinical implications of human papillomavirus in head and neck cancers. J Clin Oncology 2006;24(17):2,606-2,611.
*Dr. Ranalli is Senior Associate Dean and Professor of Pediatric Dentistry, School of Dental Medicine, Professor of Sports Medicine and Nutrition, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania, and Expert Consultant, American Academy of Pediatric Dentistry, Committee on the Adolescent. Email address is email@example.com.
*Dr. Studen-Pavlovich is Professor and Chair, Department of Pediatric Dentistry, Director, Advanced Pediatric Dentistry Program, University of Pittsburgh, Pittsburgh, Pennsylvania, and Chair, American Academy of Pediatric Dentistry, Committee on the Adolescent.