BEST PRACTICES: ADOLESCENT OHC

Adolescent Oral Health Care

Latest Revision How to Cite: American Academy of Pediatric Dentistry. Adolescent
2020 oral health care. The Reference Manual of Pediatric Dentistry. Chicago,
Ill.: American Academy of Pediatric Dentistry; 2021:267-76.

Abstract
This best practice presents general recommendations for managing the distinct oral health care needs of adolescents. Accurate medical,
dental, and social histories are necessary for safe and effective care. Health history forms should allow youth to provide information on
topics such as gender, diet, piercings, and risk-taking behaviors (e.g., tobacco, alcohol, and drug use; sexual activity). Transgender and
gender diverse youth may be at increased risk for oral, physical, and psychosocial conditions (e.g., perimyolysis due to bulimia). The age
and stage of adolescence (early, middle, late) will impact diagnostic, preventive, and restorative treatment decisions. Each adolescent oral
health topic (caries, fluoride use, oral hygiene, diet management, sealants, professional preventive treatment, restorative dentistry, periodontal
disease, malocclusions, third molars, temporomandibular joint disorders, congenitally missing teeth, ectopic eruption, traumatic injuries,
and esthetic concerns) has specific recommendations. Assent is an important aspect of adolescent oral health care that can foster the
patient’s emerging independence. Transition to adult dental care should be discussed as the patient approaches the age of majority and
implemented at a time agreed upon by the patient, parent, and practitioner. Due to the complexity of their unique needs and psychosocial
influences, creating and maintaining trust and confidentiality are important when providing oral health care for adolescents.
This document was developed through a collaborative effort of the American Academy of Pediatric Dentistry Councils on Clinical Affairs
and Scientific Affairs to offer updated information and recommendations regarding the management of oral health care for adolescents.

KEYWORDS: ADOLESCENT, ORAL HEALTH, ORAL SUBSTANCE ABUSE, RISK HEALTH BEHAVIOR, TONGUE PIERCING, TRANSITION TO ADULT CARE

Purpose marriage, parenthood), and the effect of unprecedented social

The American Academy of Pediatric Dentistry (AAPD) forces such as social media. 3 Rather than age 10-19 years,
recognizes that the adolescent patient has unique needs. This it has been defined as the period between 10 and up to 24
best practice addresses these unique needs and proposes general years.3 The American Academy of Pediatrics divides adoles-
recommendations for their management. This best practice cence into three age groups including early (ages 11-14),
serves as a summary document; more detailed information middle (ages 15-17), and late (ages 18-21).4
regarding these topics is provided in referenced AAPD oral The adolescent patient is recognized as having distinctive
health policies and clinical practice guidelines. needs5 due to: (1) a potentially high caries rate; (2) a tendency
for poor oral hygiene, nutritional habits, and routine oral
Methods health care access; (3) increased risk for periodontal disease
This best practice was developed by the Clinical Affairs Com- and traumatic injury; (4) an increased esthetic desire and
mittee and adopted in 1986.1 This document by the Council awareness; (5) increased risk for periodontal disease and trau-
on Clinical Affairs is a revision of the previous version, last matic injury; (6) dental phobia; (7) potential use of tobacco,
revised in 2015.2 The update includes an electronic search nicotine, alcohol, and other recreational drugs; (8) desire for
using the term adolescent combined with: dental, gingivitis, oral piercings; (9) increased risk of pregnancy or sexually
oral piercing, sealants, oral health, caries, tobacco use, dental transmitted infections; (10) eating disorders; and (11) unique
trauma, orofacial trauma, periodontal, dental esthetics, smoke- social and psychological needs.6-11
less tobacco, nutrition, and diet; fields: all; limits: humans, Treatment of the adolescent patient can be multi-faceted
English, clinical trials. The reviewers agreed upon the inclusion and complex. Accurate, comprehensive, and up-to-date medi-
of 105 electronic and hand searched articles that met the cal, dental, and social histories are necessary for correct
defined criteria. When data did not appear sufficient or were diagnosis and effective treatment planning. Familiarity with
inconclusive, recommendations were based upon expert and/ the patient’s medical history is essential for decreasing the
or consensus opinion by experienced researchers and clinicians. risk of aggravating a medical condition while rendering dental

Background
Adolescence refers to the period of accelerated biological ABBREVIATIONS
AAPD: American Academy Pediatric Dentistry. HPV: Human papil-
growth, changes, and social role transitions that bridges the
loma virus. NaF: Sodium fluoride OHRQoL: Oral health-related
gap from childhood to adulthood.3 The definition of adoles- quality of life. SHCN: Special health care needs. TMJ: Temporo-
cence has changed due to accelerated onset of puberty, delayed mandibular joint.
timing of role transitions (e.g., completion of education,

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care. In some cases, the parent or family members are unaware Recommendation: The adolescent should receive maximum
of certain conditions affecting/facing the adolescent patient. fluoride benefit dependent on risk assessment:29,30
The dental practitioner needs to assure the adolescent patient • brushing teeth twice a day with a fluoridated dentifrice
of trust and confidentiality in certain situations. If the parent is recommended to provide continuing topical benefits.27
is unable to provide adequate details regarding a patient’s • professionally-applied fluoride treatments should be
medical history, consultation with the medical health care based on the individual patient’s caries-risk assessment,
provider may be indicated.12 as determined by the patient’s dental provider.27,29
There is a growing number of adolescents who experi- • home-applied prescription strength topical fluoride prod-
ence gender dysphoria and may be considering or undergoing ucts (e.g., 0.4 percent stannous fluoride gel, 0.5 percent
gender identity-related medical and health care services.13,14 fluoride gel or paste, 0.2 percent sodium fluoride [NaF]
The current prevalence of transgender and non-conforming rinse) may be used when indicated by an individual’s
youth is about two percent. 15 Health history forms should caries pattern or caries risk status.27
allow youth to provide information on gender, legal and pre- • systemic fluoride intake via optimal fluoridation of
ferred name, and preferred pronouns.16 Dental office staff drinking water or professionally-prescribed supplements
should determine preferences, and terminology used should be is recommended to 16 years of age. Supplements should
consistent by all staff. Transgender and gender diverse youth be given only after all other sources of fluoride have been
may be at increased risk for eating disorders or substance use evaluated.27
disorders.17,18 Special attention should be given to identifying
dental and systemic conditions that may be linked to such Oral hygiene: Adolescence can be a time of heightened caries
disorders. activity and periodontal disease due to an increased intake of
cariogenic substances and inattention to oral hygiene proce-
Recommendations dures.21 Adolescents become more independent and tooth-
This best practice addresses some of the special needs within the brushing may become less of a priority. Adolescent patients
adolescent population and proposes general recommendations need encouragement and motivation to brush with fluoridated
for their management. toothpaste and floss regularly. Discussions regarding oral
hygiene can highlight the benefit of the topical effect of
Caries fluoride, removal of plaque from tooth surfaces, and also
Adolescence marks a period of significant caries activity for decrease halitosis and improve esthetics.8,31
many individuals. Research suggests that the overall caries Recommendations:
rate is declining, yet remains highest during adolescence.19 1. Adolescents should be educated and motivated to main-
Immature permanent tooth enamel,20 a total increase in sus- tain personal oral hygiene through daily plaque removal,
ceptible tooth surfaces, and environmental factors such as diet, including flossing, with the frequency and technique
independence to seek care or avoid it, a low priority for oral based on the individual’s disease pattern and oral hygiene
hygiene, and additional social factors also may contribute to needs.31
the upward slope of caries during adolescence.21-25 Untreated 2. Professional removal of plaque and calculus is recom-
dental caries and missing teeth have been shown to have a neg- mended highly for the adolescent, with the frequency
ative impact on oral health-related quality of life (OHRQoL), of such intervention based on the individual’s assessed
however, restored teeth were not associated with worse risk for caries/periodontal disease as determined by the
OHRQoL.26 It is important for the dental provider to empha- patient’s dental provider.31,32
size the positive effects that fluoridation, professional topical
fluoride treatment, routine professional care, patient education, Diet management: Many adolescents are exposed to and con-
and personal hygiene can have in counteracting the changing sume high quantities of refined carbohydrates and acid-
pattern of caries in the adolescent population.6-8 containing beverages in the form of soda, high-energy sports
drinks, and junk food and with introduction of coffee.8,22,23,25,33
Management of caries The adolescent can benefit from diet analysis and modification.
Primary prevention Recommendation: Diet analysis, along with professionally-
Fluoride: Fluoridation has proven to be safe and highly effective determined recommendations for maximal general and dental
in prevention and control of caries.27 The adolescent can benefit health, should be part of an adolescent’s dental health man-
from fluoride throughout the teenage years and into early agement.34
adulthood.8 Although the systemic benefit of fluoride incor-
poration into developing enamel is not considered necessary Sealants: Sealant placement is an effective caries-preventive
past 16 years of age, topical benefits can be obtained through technique that should be considered on an individual basis.
optimally-fluoridated water, professionally-applied and pre- Sealants have been recommended for any tooth, primary or
scribed compounds, and fluoridated dentifrices.28,29 permanent, that is judged to be at risk for pit and fissure car-
ies.7,23,36-38 Caries risk may increase due to changes in patient

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habits, oral microflora, or physical condition, and unsealed Periodontal diseases

teeth subsequently might benefit from sealant applications.37 Adolescence can be a critical period for the human being’s
Recommendations: Adolescents at risk for caries should periodontal status. Epidemiologic and immunologic data sug-
have sealants placed. An individual’s caries risk may change gest that irreversible tissue damage from periodontal disease
over time; periodic reassessment for sealant need is indicated begins in late adolescence and early adulthood.10,43 Gingival
throughout adolescence.37 disease becomes prevalent in adolescence.44,45 Dental caries,
mouthbreathing, crowding, and eruption of teeth predispose
Secondary prevention adolescents to gingivitis.44 Hormonal changes during adoles-
Professional preventive care: Professional preventive dental cence are suspected to be a cause of the increased prevalence45,
care, on a routine basis, may prevent oral disease or disclose with studies suggesting that the increase in sex hormones
existing disease in its early stages. The adolescent patient during puberty affects the composition of the subgingival
whose oral health has not been monitored routinely by a microflora by modifying the gingival inflammatory response
dentist may have advanced caries, periodontal disease, or other and causing exaggerated gingival inflammation, even in the
oral involvement urgently in need of professional evaluation presence of a small amount of plaque.44 Other studies suggest
and extensive treatment. circulating sex hormones may alter capillary permeability and
Recommendations: increase fluid accumulation in the gingival tissues, and this
1. Timing of periodic oral examinations should take into inflammatory gingivitis is believed to be transient as the body
consideration the individual’s needs and risk indicators accommodates to the ongoing presence of the sex hormones.46
to determine the most cost-effective, disease-preventive Conditions affecting the adolescent include, but are not
benefit to the adolescent.30 limited to, dental plaque biofilm gingivitis, non-dental
2. Initial and periodic radiographic examination should be plaque-induced gingival disease, periodontitis (including
part of a clinical evaluation. The type, number, and fre- chronic and aggressive forms), necrotizing periodontitis, peri-
quency of radiographs should be determined only after odontitis as a manifestation of systemic disease, periodontal
an oral examination and history taking. Previously ex- abscess, endodontic-periodontal lesions, mucogingival deformi-
posed radiographs should be available, whenever possible, ties (i.e., gingival recession), occlusal trauma, and peri-implant
for comparison. Currently accepted recommendations diseases.44,45 The severity of periodontal conditions are assessed
for radiographic exposures (i.e., appropriate films based by clinical and radiographic examination and can be further
upon medical history, caries risk, history of periodontal characterized by staging and grading the clinical presentation.47
disease, and growth and development assessments) should Early diagnosis of periodontal disease in children is important,
be followed.38 especially when there are systemic risk factors (e.g., poorly-
controlled diabetes, leukemia, smoking, malnutrition). Refer
Restorative dentistry: There is data to suggest arrest or reversal to the AAPD’s Best Practice on the Classification of Periodontal
of noncavitated caries lesions using sealants, five percent NaF Diseases in Infants, Children, Adolescents and Individuals with
varnish, 1.23 percent acidulated phosphate fluoride (APF) gel, Special Health Care Needs for further information.44 Personal
and 5000 parts per million fluoride toothpaste for specific sites oral hygiene and regular professional intervention can help
in primary and permanent teeth and, in advanced cavitated minimize occurrence of these conditions and prevent irre-
carious lesions on primary teeth, the use of 38 percent silver versible damage.
diamine fluoride (SDF).39 In cases where remineralization of Recommendations: The adolescent will benefit from an in-
non-cavitated, demineralized tooth surfaces is not successful, as dividualized preventive dental health program, which includes
demonstrated by progression of carious lesions, dental restora- the following items aimed specifically at periodontal health:
tions are necessary. Preservation of tooth structure, esthetics, • patient education emphasizing the etiology, character-
and each individual patient’s needs must be considered when istics, and prevention of periodontal diseases as well as
selecting a restorative material.40 Molars with extensive caries self-hygiene skills.45,48,49
or malformed, hypoplastic or hypomineralized enamel for • a personal, age-appropriate oral hygiene program in-
which traditional amalgam or composite resin restorations are cluding plaque removal, oral health self-assessment, and
not feasible may require full coverage restorations.37 Small diet. Sulcular brushing and flossing should be included
noncavitated interproximal carious lesions and facial post in plaque removal, and frequent follow-up to determine
orthodontic white spot lesions may be treated by resin adequacy of plaque removal and improvement of gingival
infiltration.37,41,42 health should be considered.48-50
Recommendation: Each adolescent patient and restoration • periodontal assessment during initial and routine dental
must be evaluated on an individual basis. Preservation of non- examinations with professional intervention, the fre-
carious tooth structure is desirable. Referral should be made quency of which should be based on individual needs
when treatment needs are beyond the treating dentist’s scope and should include evaluation of personal oral hygiene
of practice.37 success, periodontal status, and potential complicating
factors such as malocclusion, medical/systemic conditions

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or habits that predispose to periodontal disease. Compre- maximize progress.56 Optimal oral hygiene and routine
hensive periodontal examination includes an assessment dental examinations are important to prevent deminer-
of gingival topography; probing depth; recession; attach- alization during orthodontic treatment.
ment levels; bleeding on probing; suppuration; furcation;
presence and degree of plaque, calculus, and gingival Third molars: Third molars can present acute and chronic
inflammation; mobility of teeth; periodontal charting; problems for the adolescent. Impaction or malposition leading
and radiographic periodontal diagnosis should be a to such problems as pericoronitis, caries, cysts, or periodontal
consideration when caring for the adolescent. The extent problems merits evaluation for removal.57-59 The role of the
and nature of the periodontal evaluation should be third molar as a functional tooth also should be considered.
determined professionally on an individual basis. Those Recommendations: Evaluation of third molars, including
patients with progressive periodontal disease should be radiographic diagnostic aids, should be an integral part of the
referred when the treatment needs are beyond the treating dental examination of the adolescent.31 Refer to the AAPD’s
dentist’s scope of practice.44,45,48,49 Best Practices on Management Considerations for Pediatric Oral
• appropriate evaluation for procedures to facilitate or- Surgery and Oral Pathology.57 Referral should be made if treat-
thodontic treatment including, but not limited to, tooth ment needs are beyond the treating dentist’s scope of practice.
exposure, frenectomy, fiberotomy, gingival augmentation,
and implant placement.45 Temporomandibular joint (TMJ) problems: Disorders of the
TMJ can occur at any age, but symptoms appear more prev-
Occlusal considerations alent in adolescence.60,61 A recent study reported that adolescent
Malocclusion can be a significant treatment need in the adoles- females had more TMJ disorders than males.52
cent population as both environmental and/or genetic factors Recommendations: Evaluation of the TMJ and related
come into play. Although the genetic basis of much maloc- structures should be a part of the examination of the adoles-
clusion makes it unpreventable, numerous methods exist to cent. An adolescent comprehensive dental examination should
treat the occlusal disharmonies, temporomandibular joint incorporate a screening evaluation of the TMJ and surrounding
dysfunction, periodontal disease, and disfiguration which may area to include a screening history for symptoms, clinical
be associated with malocclusion. Within the area of occlusal examination and evaluation of jaw movements and, if
problems are several tooth/jaw-related discrepancies that can indicated, radiographic imaging. Referral should be made
affect the adolescent. Third molar malposition and temporo- when the diagnostic and/or treatment needs are beyond the
mandibular disorders require special attention to avoid treating dentist’s scope of practice.57,60,61
long-term problems. Congenitally missing teeth present complex
problems for the adolescent and often require combined Congenitally missing teeth: The impact of a congenitally miss-
orthodontic, restorative, and prosthodontic care for satisfactory ing permanent tooth on the developing dentition can be
resolution. significant.62 When treating adolescent patients who are con-
genitally missing teeth, many factors (e.g., esthetics; patient
Malocclusion: Any tooth/jaw positional problems that present age; growth potential; orthodontic, periodontal, and oral
significant esthetic, functional, physiologic, or emotional dys- surgical needs) must be taken into consideration.56,62-64
function are potential difficulties for the adolescent. These can Recommendations: Evaluation for patients who are
include single or multiple tooth malpositions, tooth/jaw size congenitally missing permanent teeth should include both
discrepancies, and craniofacial disfigurements. Malocclusion immediate and long-term management. Referral should be
can affect the oral health quality of life for adolescents. Ado- made when the treatment needs are beyond the treating
lescents with Class II and III malocclusions or anterior overjet dentist’s scope of practice. Due to the complexity of the
greater than six millimeters reported a significant impact on growing adolescent, a team approach may be indicated.62,65
their oral health related quality of life.51-55
Recommendations: Ectopic eruption: Abnormal eruption patterns of the adoles-
1. Malposition of teeth, malrelationship of teeth to jaws, cent’s permanent teeth can contribute to root resorption, bone
tooth/jaw size discrepancy, skeletal malrelationship, or loss, gingival defects, space loss, and esthetic concerns. Early
craniofacial malformations or disfigurement that presents diagnosis and treatment of ectopically erupting teeth can re-
functional, esthetic, physiologic, or emotional problems sult in a healthier and more esthetic dentition. Prevention and
for the adolescent should be referred for evaluation when treatment may include extraction of deciduous teeth, surgical
the treatment needs are beyond the treating dentist’s intervention, and/or endodontic, orthodontic, periodontal,
scope of practice. and/or restorative care.66-68
2. Treatment of malocclusion by a dentist should be based Recommendations: The dentist should be proactive in diag-
on professional diagnosis, available treatment options, nosing and treating ectopic eruption and impacted teeth in
patient motivation and readiness, and other factors to the young adolescent.57 Early diagnosis, including appropriate

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radiographic examination,38 is important. Referral should be upon correct diagnosis and consideration of eruption pattern
made when the treatment needs are beyond the treating den- of the permanent dentiton.76 The dentist must determine the
tist’s scope of practice.65 appropriate mode of treatment. Use of bleaching agents,
microabrasion, placement of an esthetic restoration, or a com-
Traumatic injuries bination of treatments all can be considered.77,78
Epidemiological studies have shown up to 25 percent of adol- Recommendations: For the adolescent patient, judicious
escents and adults experienced dental trauma, with most of use of bleaching can be considered part of a comprehensive,
these injuries involving maxillary central incisors from falls, sequenced treatment plan that takes into consideration the
collisions, playing sports, accidents, violence, or recreational patient’s dental developmental stage, oral hygiene, and caries
activities.69-71 The prevalence of injuries reported from studies status. A dentist should monitor the bleaching process, ensur-
around the world shows a wide range from six percent to 59 ing the least invasive, most effective treatment method. Dental
percent, depending on the country and type of injury.70 Dental professionals also should consider possible side effects when
traumatic injuries are associated mostly commonly with falls contemplating dental bleaching for adolescent patients.78-80
or collisions, and males are more frequently injured across all
age groups.69 All sporting activities have an associated risk of Tobacco, nicotine, alcohol, and recreational drug use: Signifi-
orofacial injuries due to falls, collisions, and contact with hard cant oral, dental, and systemic health consequences and death
surfaces.72 The administrators of youth, high school, and col- are associated with all current forms of tobacco use. These
lege organized sports have demonstrated that dental and facial include the use of products such as cigars, cigarettes, snuff,
injuries can be reduced significantly by introducing mandatory hookahs, smokeless tobacco, pipes, bidis, kreteks, dissolvable
protective equipment such as face guards and mouthguards.73 tobacco, and electronic cigarettes.81 Smoking and smokeless
Additionally, youth participating in leisure activities such as tobacco use are initiated and established primarily during
skateboarding, roller skating, trampolining, and bicycling also adolescence.82-85 There is increased risk in oral cancer from
benefit from appropriate use of mouthguards and protective chewing tobacco and an increased risk of lung and pancreatic
equipment.8,74,75 Long-term sequelae of traumatic injuries cancers, cardiovascular disease, stroke, and risk-taking behav-
can affect well-being, speech, need for complex care, and oral iors with use of nicotine, e-cigarettes, vaping, alcohol, and
health-related quality of life.8 recreational drugs.86 In addition, use of these substances can
Recommendations: Timely management of traumatic dental have effects such as halitosis, extrinsic staining, and negative
injuries is very important. There is a need for greater aware- outcomes in sports performance.8
ness of and education regarding the importance of timely Recommendations: The oral and systemic consequences of
management of dental trauma.69 Dentists should introduce a all current forms of tobacco use should be part of each pa-
comprehensive trauma prevention program to help reduce the tient’s oral health education.87-89 For those adolescent patients
incidence of traumatic injury to the adolescent dentition. This who use tobacco products, the practitioner should provide or
prevention plan should consider assessment of the patient’s refer the patient to appropriate educational and counseling
sport or activity, including level and frequency of activity.73 services.90 Questions regarding tobacco use should be added to
Once this information is acquired, recommendation and the adolescent dental record.91 When associated pathology is
fabrication of an age-appropriate, sport-specific, and properly- present, referral should be made if the treatment needs are
fitted mouthguard/faceguard can be initiated.73 Players should beyond the treating dentist’s scope of practice. This is further
be warned about altering the protective equipment that will discussed in the AAPD’s policies on tobacco use, nicotine
disrupt the fit of the appliance. In addition, players and delivery systems, and substance abuse.87-89
parents must be informed that injury may occur even with
properly-fitted protective equipment.73 Oral piercing: Intraoral and perioral piercing can have local
and systemic adverse effects.92,93 Risks include, but are not
Additional considerations in oral/health care of the adolescent limited to, pain, bleeding, swelling, hematoma, delayed healing,
The adolescent can present particular psychosocial character- nerve damage, abscess, blood-borne infections (hepatitis B or
istics that impact the health status of the oral cavity, care C, human immunodeficiency virus [HIV], Epstein-Barr virus
seeking, and compliance. The self-concept development pro- [EBV], tetanus, tuberculosis), endocarditis, metal hypersensi-
cess, emergence of independence, and the influence of peers tivity, choking from loose jewelry, enamel fractures, gingival
are just a few of the psychodynamic factors impacting dental trauma, periodontal recession, speech impediment, and swal-
health during this period.6,9,28 lowing difficulties or aspiration.8,93-95
Recommendations: Piercing and the use of jewelry on
Esthetic concerns: Desire to improve esthetics of the dentition intraoral and perioral tissues should be discouraged due to
by tooth whitening and removal of stained areas or defects can potential for pathologic conditions and sequelae.93 Prevention
be a concern of the adolescent. Indications for the appropriate of complications begins with oral health education regarding
use of tooth-whitening methods and products are dependent these adverse effects.95

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Pregnancy: The pregnant adolescent can be affected by Recommendations:

physiological changes to the oral cavity (e.g., gingivitis, 1. An adolescent’s oral health care should be provided by a
pregnancy-associated dry mouth, pyogenic granuloma).96 dentist who has appropriate training in managing the
Recommendations: Proper screening for pregnancy is part patient’s specific needs. Referral should be made when
of care of the adolescent female patient. Comprehensive care the treatment needs are beyond the treating dentist’s
during pregnancy should involve assessment of caries and scope of practice. This may include both dental and
periodontal disease risks along with discussion of the import- non-dental problems.102 Consultation with non-dental
ance of a healthy diet, fluoride, and oral hygiene.96 professionals or a team approach may be indicated.
2. Supplemental medical history topics regarding questions
Sexually-transmitted infections: There is a growing concern on pregnancy, alcohol and drug use, oral piercings,
and increase in the prevalence of sexually transmitted disease in tobacco use, sexual activity, and eating disorders should
adolescents, specifically in the ages of 15-19 years.11 Screening be included in the adolescent dental record.91
and examination for oral signs of sexually transmitted infections 3. Attention should be given to the particular psychosocial
and appropriate management or referral by the provider are aspects of adolescent dental care. Other issues such as
important. Because human papilloma virus (HPV) has shown assent, confidentiality, and compliance should be ad-
a relationship with oral and oropharyngeal cancers, dentists dressed in the care of these patients.101,103
are in a unique position to discuss the HPV vaccination with 4. A complete oral health care program for the adolescent
patients and their parents.97 requires an educational component that addresses the
Recommendations: Screening and examination for oral particular concerns and needs of the adolescent patient
signs of sexually transmitted diseases should be part of com- and focuses on:
prehensive care delivered to the adolescent patient. The a. specific behaviorally- and physiologically-induced
examination should include identifying oral manifestations of oral manifestations in this age group;31
sexually-transmitted diseases as well as education on the risk b. shared responsibility for care and health by the
of transmission during unprotected oral sex and adoption of adolescent, parent, and provider;31 and
barrier techniques (e.g., condoms, dental dams) for prevention; c. consequences of adolescent behavior on oral health.8
referral for counseling and treatment is recommended when
indicated.11 Patients also should be educated on HPV and Transitioning to adult care: As adolescent patients approach
available vaccination to prevent risk of infection.97 the age of majority, it is important to educate the patient and
parent on the value of transitioning to a dentist who is knowl-
Psychosocial and other considerations: Behavioral considerations edgeable in adult oral health care. The adult’s oral health
when treating an adolescent may include anxiety, phobia, and needs may go beyond the scope of the pediatric dentist’s
intellectual dysfunction.21 Some psychosocial considerations training. The transitioning adolescent should continue pro-
may result in oral problems (e.g., perimyolysis/severe enamel fessional oral health care in an environment sensitive to his/
erosion in patients with bulimia).98 her individual needs. Many adolescent patients independently
The impact of psychosocial factors relating to oral health will choose the time to seek care from a general dentist and
must include consideration of the following: may elect to seek treatment from a parent’s primary care
• changes in dietary habits (e.g., fads, freedom to snack, provider. In some instances, however, the treating pediatric
increased energy needs, access to carbohydrates). dentist will be required to suggest transfer to adult care.
• use of tobacco, alcohol, and drugs. Pediatric dentists are concerned about decreased access
• risk-taking or risk-seeking behavior. to oral health care for individuals with special health care
• motivation for maintenance of good oral hygiene. needs (SHCN)104 as they reach the age of majority. Pediatric
• adolescent as responsible for care. hospitals, by imposing age restrictions, can create a barrier
• lack of knowledge about periodontal disease. to care for these patients. Transitioning to a dentist who is
knowledgeable and comfortable with adult oral health care
Physiologic changes also can contribute to significant oral needs is important and, in some instances, difficult due to a
concerns in the adolescent. These changes include: (1) loss of lack of trained providers willing to accept this responsibility.
remaining primary teeth; (2) eruption of remaining perma- Successful transitioning from pediatric to adult special needs
nent teeth; (3) gingival maturity; (4) facial growth; and (5) dentistry involves the patient and his caregiver(s), adequate
hormonal changes. preparation, and understanding of the complex situations
Although new studies show that neurologic maturation relating to care.105
continues into the third decade of life, seeking assent from Recommendations: At a time agreed upon by the patient,
adolescents for intervention can foster the moral growth parent, and pediatric dentist, the patient should be transitioned
and development of autonomy in young patients.99,100 Refer to a dentist knowledgeable and comfortable with managing
to AAPD’s Best Practice on Informed Consent for further that patient’s specific oral care needs. For the patient with
information.101 SHCN, in cases where it is not possible or desired to transition

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to another practitioner, the dental home can remain with the Wellness. Ensuring comprehensive care and support for
pediatric dentist and appropriate referrals for specialized dental transgender and gender-diverse children and adolescents.
care should be recommended when needed.103 Pediatrics 2018;142(4):e20182162.
14. Kaltiala-Heino R, Bergman H, Tyolajarvi M, Frisen L.
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