JCAPN Volume 20, Number 1, February, 2007 1

Blackwell Publishing Inc

EDITORIAL

EditorialEditorial

Editorial

A Holistic Approach to Child Psychiatric Nursing: A New Interdisciplinary Collaboration

Clinicians who practice in child psychiatric nursing are very familiar with collaboration and work with a variety of healthcare professionals every day to provide the best outcomes for their clients. The interdisciplinary team often includes other nurses, psychiatrists, pediatricians, social workers, psychologists, and so on. There is a discipline not commonly part of the team, but should play an important role in caring for children and adolescents. The most common chronic childhood disease is dental decay, affecting 50% of children by middle childhood and 70% by late adolescence (American Academy of Pediatric Dentistry, 2004). Yet, how many assessments in a psychiatric setting include a complete and thorough exam of the child’s mouth and teeth? How many psychiatric/mental health nurses know what to look for and how to identify problems in the mouth? We need to add to our team an expert in prevention and treatment of diseases and problems in the mouth, including teeth. We need to add the dental hygienist to our team.

The past few years have seen increasing evidence confirming the relationship between oral health and total body health. Talk about co-occurring or dual diagnoses: a child’s behavior may be a result of or accelerated because of a dental problem. Those of us who are the veterans in the crowd might remember the staining of teeth from anticonvulsants, but have we continued to consider the effects of medications and self-stimulating behavior on the mouth and teeth? Oral health means more than just teeth free from decay. It is integral to general health and well-being. It means being free from chronic oral facial pain, intraoral lesions, oral cancer, and birth defects such as cleft palate and lip. Oral diseases restrict activities in school and at home, causing loss of school and activity hours each year. In addition, the psychosocial impact of these conditions can significantly affect the child’s mood and behavior. Many oral problems can be prevented or treated, especially with a combination of interdisciplinary and collaborative action between nursing and dental hygiene.

A thorough oral exam can detect active caries activity as well as nutritional deficiencies, microbial infections, and injuries. For instance, delayed growth or slow weight gain may point to a lack of interest in eating due to pain. The mouth is not only the gateway to the body; it can be a mirror as well. Clients struggling with eating disorders may present with an

increase in caries, periodontal disease, or immature permanent tooth enamel (American Academy of Pediatric Dentistry, 2005). Adolescents are more prone to traumatic injury to teeth, and intraoral and periodontal piercing may increase susceptibility to injury and infection. Hormonal changes, antibiotics, and birth-control pills may also cause damage to teeth and oral health. Drug misuse and tobacco use have a negative effect on the teeth. Venereal diseases can cause oral lesions. The growing use of mouth grills by middle school children and young adolescents has added to the need for good mouth hygiene. Just normal growth of the head and face can lead to difficulties such as ectopic eruption of permanent teeth, malocclusion, or temporomandibular joint problems. Periodontal disease in adolescence can lead to irreversible gum tissue damage.

The health of the mouth and teeth can also play a role in diagnosing neglect and abuse in children. Poor nutrition and lack of parenting skills can lead to unhealthy teeth. For example, early childhood caries is an infection that arises from bacterial plaque biofilm that forms on the teeth. One of the many micro-organisms in plaque that builds up on teeth is the streptococcus group.

Streptococcus mutans

is considered to be cariogenic and acidogenic

.

Lactic acid is a by-product as these bacterium metabolize carbohydrates. This acid can lead to decay of the tooth enamel. When parents or caregivers place sugary solutions in baby bottles, acid is quickly produced and the decay process begins. Even lactose in milk can provide enough energy for this bacterial process to occur, especially if the bottle is kept in the mouth too long. It is essential to note that the most important consideration is the amount of time the teeth are exposed to the liquid, whether it is breast milk, milk, or juice. For that reason, spill-proof training cups often used with toddlers are another area of concern because they also encourage continuous sipping (American Academy of Pediatric Dentistry, 2003).

The average age of early childhood caries onset is between 18 and 36 months. The first deciduous tooth erupts at around 6 months of age, and is usually a mandibular central incisor. Early childhood caries can cause the maxillary anterior deciduous teeth to be severely decayed to the gumline by the time a child is 18 months old. When the child drinks, maxillary anterior teeth are bathed in the pool of liquid that sits on the tongue. Mandibular anterior teeth are

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Editorial

protected by the tongue that lays over them. Because maxillary anterior permanent teeth do not erupt until the age range of 5–7 years, problems with appearance, eating, and speech stem from early tooth loss. If enough tooth structure remains, the teeth can be restored. Otherwise, spacing issues arise throughout the dentition since deciduous teeth hold the place for permanent teeth.

In August 2005, the CDC released a report stating that although dental caries is decreasing in 6- to 19-year-olds, it is increasing in 2- to 5-year-olds. While the report calls for a number of actions, the American Academy of Pediatric Dentistry (2005) recommends, among other things, that medical and dental-care providers continue to develop, adopt, and evaluate clinical protocols for early risk identification and preventive intervention. Although children should see a dentist by age 2, often healthcare providers other than dental professionals are the only care providers to examine infants, children, and even adolescents. Initial screening of teeth and the oral cavity should be included in all assessments so referral to dental providers can be made to address problems or to implement preventive interventions such as fluoride treatments.

Nurses can also convey a wide range of helpful messages to the parents and caregivers of children. Keeping the child’s mouth clean with a soft bristled toothbrush dampened with water can keep the teeth and gums plaque free so that harmful acids cannot attack the teeth. Parents should know that they need to help their children brush until they have the dexterity to brush and floss alone. Mouth care of children with developmental delays and/or any hand-coordination problem can be a challenge for caretakers because the children may not be cooperative and often have increased needs because the children hold food in their mouth or have a tight temporomandibular joint. There are aids to help prevent tooth decay, such as sealants, which are thin plastic coatings for the occlusal surfaces of molars and premolars. Sealants can protect chewing surfaces for many years because they create a barrier to block plaque acids that lead to decay. Fluoride, a mineral that bonds with tooth enamel to create a harder tooth surface, is helpful in

prevention and is available for topical or systemic application. For example, there is toothpaste with fluoride available by prescription.

Psychiatric/mental health nurses and dental hygienists share a common concern for children and adolescents. Their areas of expertise complement each other, especially when working with children with special needs. Yet, the collaboration of nursing and dental hygiene is just evolving. There is a growing body of science of oral systemic medicine and the interaction of body and mind. We believe that holistic care should consider the affects of what could be hidden problems in a child’s mouth. With the expansion of the interdisciplinary team to include a dental hygienist, we may be able to help children remain pain free and healthy. A true holistic approach would assess and treat the total body. It seems very appropriate that nurses and dental hygienists should join efforts to help children reach their potential.

Nancy K. Mann, RDH, MSEd

Clinical Associate Professor, Dental EducationCollege of Health and Human Services

Indiana University—Purdue University Fort Wayne

Linda M. Finke, PhD, RN

Dean and ProfessorCollege of Health and Human Services

Indiana University—Purdue University Fort Wayne

Author contact: finkel@ipfw.edu, with a copy to the Editor: Poster@uta.edu

References

American Academy of Pediatric Dentistry. (2003). Policy on earlychildhood caries (EEC): Classification, consequences, and pre-ventive strategies. Chicago: American Academy of PediatricDentistry.

American Academy of Pediatric Dentistry. (2004).

Clinical guidelineon infant oral health care

. Chicago: American Academy of PediatricDentistry.

American Academy of Pediatric Dentistry. (2005).

Clinical guidelineon adolescent oral health care

. Chicago: American Academy ofPediatric Dentistry.