Systemic diseases

Even one fifth of Finnish children have a chronic systemic disease with varying severity. The most common are allergies, asthma, neurodevelopmental disorders, coeliac disease, type I diabetes (DM I) and autoimmune diseases of which juvenile idiopathic arthritis (JIA) is the most common. The proportion of children diagnosed with obesity, inflammatory bowel disease (IBD), DM I, and JIA as well as with organ transplants, operated heart conditions and the survivors of childhood cancer, has been increasing in recent years (3). In Finland, 500 children (<1 %) and adolescents are diagnosed with DM I annually, while the number is 400 children for congenital heart diseases and 150 children for JIA. Chronically ill children often have a higher risk of oral diseases compared with their healthy peers and they have special needs in dental care. For example, children with congenital heart disease comprise a risk group for dental caries (4) and diabetics are prone to gingivitis and have greater plaque accumulation (5). JIA often involves the temporomandibular joint and thereby affects the developing occlusion (6). If left untreated, poor oral health can have a devastating impact on the overall health, especially for those with certain systemic health problems and conditions. Lack of preventive and timely therapeutic care may exacerbate systemic problems. Oral health care of patients with systemic health problems often necessitates consultation with the medical specialists who treat the child and treatment may need to be rendered in hospital settings. Having pathways to ensure children’s oral health at appropriate level and way needs continuous attention

High and low BMI

In recent years snacking has replaced regular meals. Consumption of soft and energy drinks has increased, causing a threat for general as well as oral health (7). Frequent snacking and intake of sweet products are associated with overweight (8), but also with dental caries (9). Indeed, children’s overweight and obesity are common in today’s industrialized world (10). Simultaneously with dietary changes, time spent in front of TVs, PCs and mobile applications has increased at the expense of physical activity, in particular among the teens (11). Literature of the association between overweight and caries is contradictory; both high and low BMI have been shown to associate with decaying. The association appears different in countries of different developing stage (12). These issues need close monitoring in future.

Eating disorders, on the other hand, are common especially among girls, when approximately 7 % of Finnish women get such diagnosis before 30 years of age (13). Eating disorders threaten general as well as oral health. The most remarkable problem is dental erosion, in which teeth dissolve due to frequent vomiting or consumption of acid food and drinks (14) combined with occlusal forces. The prevalence of erosive tooth wear per se is increasing and a matter of concern especially among the young.

In all cases where a young patient has an eating disorder of any kind, possibility for professional nutritional counselling must be considered, in some cases even counselling to arrest erosive tooth wear. It is important to remember that an eating disorder may be a symptom of an underlying mental problem, which requires referral to psychiatric counselling.

Visions in child psychiatry

In a Finnish population-based study (n=2682) by Borg and coworkers (15), 17 % of children aged 4–9 years were reported to have psychiatric symptoms according to the Strength and Difficulties Questionnaire (SDQ, www.sdqinfo.com) filled in by parents and / or teachers. Based on the reports by physicians working in primary health care clinics, 12 % of children and families were evaluated to need treatment and support in primary health care and respectively 9 % (number of reports 2604) in specialized health care due to psychosocial problems.

There is no evidence of substantial increase in children´s mental health problems in Finland between 1989 and 2013; however, the use of mental health services has constantly increased (16). The number of referrals indicates better detection of children´s mental health problems but it might also indicate that children with mental health problems have substantial difficulties to cope in a more complex operational and emotional daily environment. Recognition of risk factors, early detection as well as prevention and care of psychosocial problems is both effective and cost-efficient (2).

Psychosocial aspects should be taken into account in every contact with a child in health care system, including dental care. All health care personnel are responsible to detect the possible risk factors and / or psychiatric symptoms and organize or refer the child and the family to appropriate evaluation, care and support. The common goal is to provide good mental health.

Children and adolescents with psychiatric issues may have difficulty even in attending routine dental check-ups and with coping with dental treatment. Again, medications may cause a reduced salivation rate and a child’s/adolescent’s motivation for good homecare maybe low, which all increase risk i.e. for dental caries. Therefore, preventive measures should be carried out frequently by the professionals and these children/adolescents should have shortened recall intervals. If necessary, for instance due to large treatment need or symptoms, these children should be treated under dental general anesthesia (DGA).

Neurodevelopmental disorders

Neurodevelopmental disorders affect about 10 % of the general child population, and the most common types being attention deficit hyperactivity disorder (ADHD) occurring in 3–6 %, language impairment in 5 %, intellectual disability in 1–2 %, autism spectrum disorders (ASD) in 1.5 %, and Tourette Syndrome and Obsessive Compulsive Disorder (OCD) in 1 %. Comorbidity between neurodevelopmental disorders is common, i.e. 50 % of children with ASD also fulfil diagnostic criteria for ADHD. Because most neurodevelopmental disorders present symptoms already at an early age, long before reaching a certain diagnosis, a concept of ESSENCE (Early Symptoms of/Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examinations) has been presented to be used for this group (17), implementation of which is a future challenge.

Dental behavior management problems are common in children with neurodevelopmental disorders (18). Such children gain from a structured dental appointment (e.g. 1000-learning), and especially children with ASD from augmentative communication (e.g. using pictures). In ADHD, executive dysfunctions lead to difficulties using previous dental experiences to decide how to react during the present dental appointment (19). ASD is characterized by impairments in social interaction and communication, restricted patterns of behavior, and unusual sensory sensitivities (DSM-5 2013). Children with ASD are impaired in building flexible predictions and expectations, which is very much needed during a dental visit. Sensory abnormalities to a greater extent affect those with severe autistic traits (20). However, in the dental setting, bright light, loud noises and strong tastes or smells offer a challenge even for those with milder sensory sensitivities.

Dental caries

Caries still is the most common chronic disease worldwide (21). If left untreated, dental caries can cause toothache, loss of function, and even dental infections that may even become life threatening. Caries with its consequences may deteriorate child’s oral health related quality of life (OHRQoL) (22) affecting child’s sleeping, playing, eating and self-esteem (23). ECC, early childhood caries, concerns only a minority of children, but deteriorates life of the children and people around them. It is often a reason for referral to DGA, even more than once (24) (figure 2).

Literature on DGAs has revealed background factors related to both family issues and negative oral health behaviors (25) (Table 1). Removing plaque and using fluoride toothpaste twice per day (26) and favoring healthy diet without snacking (27) are the means for controlling and preventing manifestations of caries disease. Oral health must not be taken for granted, but promotion must be continuous at population level. When treating children with risk for caries, it is most important to get families involved and aim to support them and help child with individual plan for caries controlling. It must always be borne in mind that DGA is not without risks. Indeed, research is needed to identify the potential risks associated with the use of general anesthesia especially for the very young children.

Periodontal disease

Children and young individuals also suffer from periodontal diseases. Plaque accumulation at the gingival margin is the major cause of gingival inflammation, which results in an environment favoring inflammophilic bacteria and may lead to a dysregulated immune response and, further, to the initiation of periodontal destruction (28). Gingivitis is common among the toddlers, but also signs of periodontitis (i.e. loss of marginal bone) can be detected already in the primary dentition. A study using bitewing radiographs, bone loss for at least one proximal site was prevalent in 4.5 % of 9-year-olds (29). In a longitudinal study the presence of subgingival calculus was connected to progression of periodontitis on periodontal conditions among teenagers (30). Smoking as well as diabetes are known to expose to periodontal disease. Association of diabetes with gingival inflammation and attachment loss was shown in a cohort study with 700 children and adolescents, and periodontal destruction was shown to occur even under the age of 12 years (31). Some evidence exists also on the association between the extent of gingival bleeding and metabolic syndrome in 8‐ to 10‐year‐old children, specifically boys (32). It is notable that in addition to local tissue damage, chronic infection in the periodontium may lead to low-grade systemic inflammation, which is associated with several systemic diseases. Careful diagnostics and considering the risk factors, are essential for detection of the disease at its early phase, and early intervention is of utmost importance in preventing the development of advanced periodontal disease and likely in providing support for general health. If any signs of aggressive periodontal disease are seen in a child, the child should be referred to a specialist in periodontology, or he/she should be consulted.