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Hope for HIE was recently honored to join forces with Dr. Juan Yepes, who serves multiple roles as a professor at Indiana University, an associate editor of the Journal of the American Dental Association, and as a pediatric dentist at Riley Children’s Hospital in Indiana, where he excels at providing specialized dental care and building educational resources for families to better understand the relationship between medical complexities and oral health. Dr. Yepes works closely with a multidisciplinary team of healthcare professionals to ensure comprehensive and integrated care for pediatric patients, especially those with medical conditions that range from asthma to more complex syndromes, such as HIE.
In the transcribed discussion below, Dr. Yepes sheds light on how HIE impacts oral health and the crucial role that dental care plays in one’s overall health and well-being.
Q: Please provide us with a brief career overview and your journey toward becoming an esteemed pediatric dentist and doctor of public health. Your research has focused on oral health in children with medical complexities. What drew you to this work?
A: Thank you so much for having me. I really love to do this. I believe that I have a responsibility with the community and with our children as a pediatric dentist to help, whether that’s by providing dental care or by sharing educational resources and tools with families. At the end of the day, we all have the same goal: we want to keep optimal oral health. This can sometimes be a challenge with a child with medical complexities, because so many priorities are being juggled at once. This is why I love working with other medical professionals and organizations, such as Hope for HIE: I get the opportunity to explain how the mouth is so critical to systemic health. There are so many repercussions related to the mouth – it can be a source of infection, a source of pain, and even an entryway for bacteria to spread to other areas of the body. Unfortunately [and those in my field have been trying to change this narrative], many may see the mouth as a completely different country; as an isolated part of our body when, in reality, it is such an important part of our whole, systemic health.
Q: What is the recommended age to begin seeing a pediatric dentist?
A: This is probably the most critical question in this conversation. According to the American Academy of Pediatric Dentistry, or AAPD, families should plan for their child to begin seeing a pediatric dentist [or a family dentist, depending on the availability of medical providers in their area] when they are around 12 months old. This may come as a surprise to many, since there are so few teeth at this age, but the goal of this visit is more around fostering productive conversations about brushing, oral care, diet, using fluoride, and the importance of establishing a “dental home” just as you would a “medical home” for your child.
Q: For children with HIE or other medical complexities, should they be seen earlier than recommended?
A: Now, in terms of whether or not a child with HIE should consider being seen earlier than the recommended age of 12 months, I’m going to answer “yes.” Each situation is different, but just for this conversation, I would recommend around 6 months of age. It all comes down to building anticipatory guidance, which I liken to a weather forecast: both provide valuable information and preparation for the future. Just as a weather forecast predicts and informs us about potential weather patterns, seeing a pediatric dentist early on and receiving anticipatory guidance helps parents and caregivers understand what to expect in their child’s oral health journey. It provides insight into the potential challenges and milestones for that child, and it enables us to create a customized plan of preventative care.
Q: Are there questions families should proactively ask or concerns they should address because of their child’s HIE diagnosis?
A: When we think about children with HIE, anticipatory guidance is key. No child is exactly the same; each child may have a range of consequences due to the varied outcomes and challenges related to this medical diagnosis. Each patient is a different world, especially from the perspective of dentistry. This is exactly why we encourage parents to ask us about what they can do to help prevent future complications as well as work together to establish a cadence of care. Perhaps, for example, a child would benefit from seeing a pediatric dentist every 3 months as opposed to a regular 6 month interval. Either way, in establishing that early visit, we can build a better understanding of what’s to come, and we can create a more customized treatment plan for every child.
Q: For children with HIE or other medical complexities, how would you recommend people find dentists who are familiar with caring for this population?
A: This is a great question. I’d love to first provide some extra context by helping to discern some of the differences between a generic dentist and a pediatric dentist. Pediatric dentists, for instance, train for an additional two years after dental school, and part of this training is devoted to helping us learn how to provide specialized care and anticipatory guidance for children with various medical complexities.
Here’s the issue, though: not every zip code has a pediatric dentist. However, the American Academy of Pediatric Dentistry [AAPD] is a great resource for this – it allows parents and caregivers to perform an advanced zip code search [with a filter for maximum mileage] to find pediatric dentists in or around their area.
I know this may not always be enough – perhaps the closest pediatric dentist is 200 miles away, and this can pose a challenge for families. In this instance, I’d urge them to go with the closest family dentist. They are a wonderful resource, for they still have a full understanding of prevention. They have a full understanding of how critical it is to brush, how critical it is to use fluoride, and how critical it is to come every 6 months or so to establish cadence of care for your child. I’m also confident that if a family dentist believes that the medical complexity of a child is beyond his or her comfort zone, that they may recommend one visit to a pediatric dentist just to gain their knowledge, expertise, or medical opinion.
Q: How can dental professionals collaborate with healthcare providers [and vice versa] to educate families on potential issues as well as monitor/ treat oral health issues as they arise?
A: Our closest friends and partners, as you could probably guess, are nurse practitioners and pediatricians. They are primary healthcare providers, just as us, and they are at the frontline of care. There is a very close and streamlined connection between pediatricians and pediatric dentists: we both play a vital role in promoting oral health awareness, conducting initial screenings, and offering anticipatory guidance. They refer patients to us, and we refer patients to them.
Now, in some situations, especially when it comes to HIE, neurologists and occupational therapists can play an important role in helping a family establish a better oral healthcare plan as well. Neurologists can provide valuable insights into how neurological conditions impact oral health and contribute to the overall treatment plan, whereas occupational therapists can assist families in establishing adaptive strategies and techniques to ensure optimal oral hygiene practices are implemented effectively.
Q: While there are still many unknowns when it comes to HIE, we do know that many babies and children with HIE go on to have dental issues.Does HIE increase the risk of developing dental cavities or tooth decay? If so, what are the contributing factors?
A: The simple answer is yes. Now, the reason behind this answer is a little more complex. Dental caries [also known as cavities] are one of the most complex diseases you can imagine. Many factors interact to produce them, to the point that even now – in the 21st century – we don’t always know why they arise. It could be related to saliva, diet, and oral hygiene, or a multitude of other factors.
Now, HIE is a risk factor that places the child at higher risk for tooth decay. There are many reasons for this; primarily, it can be related to oral hygiene. I recognize how it can be very challenging for parents to take care of their child’s oral hygiene practices, like proper brushing, due to the nature of their condition or HIE-related outcome. Secondly, HIE parents may have a multitude of medical priorities they are taking care of for their child, so oral health may not, understandably so, be at the forefront of their mind. Thirdly, we know that kids with HIE develop problems with enamel. This is the door of entry for bacteria to get into the tooth and cause dental caries.
Q: It sounds like you are referencing a common oral condition experienced by many in our community, and that is enamel hypoplasia. Can you please define enamel hypoplasia and its impact on teeth?
A: Absolutely. To begin, though, I want to provide some context about how and when enamel begins to form. I find it just amazing that tooth formation starts about 4-6 weeks after conception. This is when the cells that produce all of the parts of the tooth begin actively working together to build the tooth, or as I like to analogize it, a house. Imagine, for a multitude of reasons, that these cells didn’t produce a strong enough enamel – or roof of the house. This roof now has a bunch of holes, which makes it easier for the rain, or bacteria, to get into the foundation and cause decay.
Enamel hypoplasia is essentially the malformation of this enamel, or the destruction of this roof. Anything that happens during the pregnancy, whether it is an illness, some type of genetic factor, or a birth-related event — just to name a few — may affect how these cells produce the enamel. So, when a baby’s teeth start to emerge around 6 months, we may see some enamel defects, and this creates the perfect niche for the development of dental caries [cavities].
Q: What are some ways parents can work with their dentist to mitigate the impacts of enamel hypoplasia?
A: This is a complex question, so I want to be very clear here. It really depends on the severity of the enamel hypoplasia, which ranges from mild to moderate to severe. It could also only impact 1 tooth, or it could affect 20. The severity determines the mitigation strategy; generally speaking, the application of fluoride helps, because this makes enamel stronger. It can make the holes in the roof smaller. This is why brushing two times a day with fluoride toothpaste is essential to a child’s oral hygiene.
If a child has extensive or severe enamel hypoplasia, this may require covering the tooth with a crown, and if multiple teeth are impacted, we may need to look at other strategies or other forms of restoration.
Q: A large proportion of our HIE population takes anti-seizure medications. What might some of the implications of these ASMs be on teeth and gums? Families have reported some ASMs can cause gum overgrowth or other impacts to teeth due to the medications.
A: I could talk for hours about medications and their implications on teeth. To parents or caregivers who are reading this conversation, I’d like to say that every medication will have some type of repercussions. Some, for instance, might cause dry mouth, which hinders the creation of saliva and may be the cause of future tooth decay/cavities.
Now, these medications are obviously critical for the child’s health, so we can’t exactly advise them to stop the medication. So, if we know that a side-effect of this medication will lead to dry mouth or gingivitis, for example, we’ll place that child at the top of our care, and we’ll search for solutions. Perhaps we can approach the physician to see if they can switch to another medication. In the event that solution is not possible or probable, then we can look for other solutions, depending on the medication’s impact. For instance, with gum overgrowth, we may be able to reshape or remodel the gums.
This is why it’s so critical to see a pediatric dentist: we know that medications have the power to do this, and we can help anticipate the issues and create a plan of prevention, restoration, and care.
Q: Are there any other specific issues commonly observed in children with HIE [or others with medical complexity] that we have not yet addressed? If so, what are they?
A: Truly, there are so many, and it all comes down to understanding each individual patient. We’ve talked about enamel hypoplasia, gingivitis, and tooth decay, but there are a few more I’d like to put on the radar: the first of which is eruption delay, otherwise known as the late arrival of teeth. By the age of 3, children are supposed to have all of their baby teeth, but for children with HIE, this may take a little longer. Sometimes, especially for children with HIE, some teeth may not fall, resulting in missing baby or adult teeth. This is important to know and watch out for, because we can use strategies to preserve the space in the mouth.
I’d also like for parents, caregivers, and families to know that enamel hypoplasia, in some instances, can cause the tooth to have huge cavities beyond what we are able to save or care for, which may result in early tooth extractions.
I really hope that this conversation will help create more awareness about some of these issues. Remember, each child is different, and this is why I always go back to the importance of anticipatory care.
Q: Many parents report that their children, across many different ages, grind their teeth. Can you speak to this issue, its impacts, and what interventions or recommendations for care you’d suggest to preserve the integrity of the teeth?
A: While this is probably our most common complaint from parents and caregivers, it is important to know that, under the age of 7, grinding is not a big deal. It’s just not. Also, there’s very little we can do with young children in terms of finding a solution: we can’t use a mouthguard or bite guard, as it would prevent other teeth from coming in or growing as they need.
Grinding is very frequent in all children. It is hard to believe, but about 40-45% of children under the age of 7 do so for a number of complex reasons. Grinding in children is not an issue; it’s when they start to transition into adulthood that it poses more of a problem. That’s when we should start looking for help and finding solutions, because grinding can cause shortened or flattened teeth, the breakdown of enamel, and even jaw pain. This is such a stark contrast to grinding in children: they can grind all night, and it is likely that their teeth will be totally fine.
Q: Children with HIE are at higher risk for increased or decreased muscle tone and oral motor impacts. These can cause all sorts of issues with the growth and development of the jaw, craniofacial structure, etc. What impacts are most common from these neurological issues stemming from HIE?
A: Usually, the main issue is dexterity and its impacts on oral healthcare; specifically, the child’s ability to grab the toothbrush to perform proper oral hygiene. Each patient is different, but no matter what, parents and caregivers should help their child brush their teeth until 7 or 8 years of age and perhaps even later, depending on the child’s dexterity, muscle tone, or ability to properly brush.
We are fully aware of the issues in terms of muscle tone and ability, and we can create a customized plan for each child depending on its severity. I will say, I have had many patients with cerebral palsy, for example, and many may be surprised to know that the main issue I see in these patients is not dental decay, but rather, gingivitis, or the inflammation of the gums. This could be for a multitude of reasons: limited motor control or muscle stiffness can hinder effective brushing and flossing techniques, making it hard to remove plaque; excessive drooling can also offset the natural balance of saliva, making it easier for bacteria to grow and inflame the gums.
Q: What are some recommended preventative measures HIE children/parents can take to maintain optimal oral health?
A: Brushing, brushing, brushing. It is also super critical to use toothpaste with fluoride. I’m a dad myself, so I know how easy it is to go to the grocery store and find something called “training toothpaste” that actually doesn’t have fluoride in it for our children. As pediatric dentists, we don’t recommend this. Fluoride is our best friend – our best helper – when it comes to keeping cavities away. We recommend brushing with fluoride toothpaste twice a day, and we also reiterate the importance of helping your child brush until at least 7 years of age.
I also encourage parents and caregivers to have conversations with their child’s dentist about flossing as well as their dietary habits. It is not enough to just be away from sugar-related food; diet can play a big role in oral health. Now, this conversation can go in many different ways, depending on each child, so that is why I always go back to the idea of prioritizing visits to a pediatric or family dentist and beginning these conversations early on.
Q: Are there any long-term implications of HIE on oral hygiene and dental health that parents should be aware of as their children grow older or transition into adulthood?
A: This is a complex question, just because long-term implications are highly dependent upon the situation of that patient and their ability to have access to care, the types of medications they are using, and the range of impacts and outcomes of HIE. Where a child is on this spectrum can determine the oral challenge they have to overcome, whether it is enamel hypoplasia, gingivitis, delayed tooth eruption, or more.
As pediatric dentists, we truly appreciate parents and families and their ability to multitask and prioritize so many elements of their child’s health, but the best way to prevent these issues is to put us on the list of important medical providers to see. We do not have to be number 1 on this list, but we’d love to be included. This is truly the best way for prevention of these issues and to maximize oral health.
Q: Are there any ongoing research studies or advancements in the field of dentistry that aim to address the oral health challenges associated with HIE or other medical complexities?
A: The research is plentiful. Specifically here at Riley Children’s Hospital, we constantly try to have a better understanding of enamel hypoplasia. There’s also ongoing research about the role of medications and saliva in children with HIE and how potential saliva substitutes can mitigate the negative effects of these medications.
For additional context, I’m the associate editor of the Journal of the American Dental Association, and I edit the section of medicine and dentistry, so I view articles daily about groups around the country who are trying to better understand the implication of HIE on oral health. There’s a lot of ongoing research out there. There are a lot of doctors who are always looking to understand how to improve oral healthcare in children with various medical complexities, HIE being one of them.
Q: Do you have any suggested tools or resources for our community members to learn more about or better understand the relationship between HIE and dental and oral health impacts, prevention, treatment and continuing care?
A: The American Academy of Pediatric Dentistry, or AAPD, is my most recommended resource. It has articles, information, and brochures regarding medical issues and oral health repercussions. It discusses a wide range of medical complexities, such as HIE and cerebral palsy, and is a wonderful resource for those in the community looking for guidance and detailed answers to frequently asked questions.
I also recommend the Special Care Dentistry Association, or SCDA, because they are an organization of dental professionals who specialize in providing oral healthcare to individuals with special needs and medically-complex conditions. They offer wonderful educational resources that cover topics related to oral health in medically-complex children, such as oral hygiene techniques and preventative care, and they also do a really great job of helping families locate dentists that are equipped to provide care for children with special healthcare needs.
Q: Thank you so much for your time and for sharing your invaluable expertise. I know our families will greatly benefit from and appreciate this resource. Is there anything else you’d like to add before you depart?
A: Thank you so much for having me; it has been an honor to collaborate with Hope for HIE and provide this resource to families who may need it. As I mentioned before, I love to do this, because I think pediatric dentists have a responsibility to help connect parents and patients to educational tools, and I love to assist in bridging that health-literacy gap.
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