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

Journal of Child and Adolescent Psychiatric Nursing, Feb 2007 by Mann, Nancy K, Finke, Linda M

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 mutons 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 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.