Children’s oral health: prevention and treatment

Onikul R, et al. 20Basic oral health care is becoming a standard part of the well-child checkup. There’s good reason. Today’s most common chronic childhood disease is dental caries, which affects 42% of children aged 2 to 11 years and half of those aged 12 to 15 years.^1,2 The problem is worse for children from low-income families and some racial and ethnic groups, according to the Centers for Disease Control and Prevention (CDC).²

According to the American Academy of Pediatrics (AAP), early childhood caries is 5 times more common than asthma and 7 times more common than hay fever.³

There are immediate quality of life and health impacts to poor oral health. One example: US children miss 51 million or more school hours a year because of dental disease.¹ The pain and chewing difficulty that can result from untreated caries affect weight, speech, and concentration-all of which can negatively affect learning.⁴

Long-term consequences of poor oral health include gum disease and tooth loss, as well as diabetes, stroke, heart disease, premature births, and more.²

Also among the newly discovered potential consequences of poor oral health is human papillomavirus (HPV).⁵ Oral health issues in children can even lead to death. It did in 2007 for Deamonte Driver, a 12-year-old boy in Maryland, who died after bacteria from an abscessed tooth spread to his brain.⁶

Opening prevention’s door

One of the barriers to better oral health for children and families is access. This is exacerbated by a shortage of pediatric dentists in the United States-especially those who accept Medicaid. Only about 45% of 2- to 6-year olds in this country go to the dentist at least once in a given year; yet, the AAP and American Academy of Pediatric Dentistry (AAPD) recommend that children have an established “dental home” by 1 year of age.⁷

Given that preventive health services are delivered on a much larger scale in pediatricians’ offices, many say pediatricians are ideal front-line providers who can detect oral health issues and begin the process of care and prevention. According to proceedings from the US Surgeon General’s Workshop and Conference on Children and Oral Health in 2001, “Oral health cannot be considered separate from the rest of children’s health and well-being, just as the mouth cannot be separated from the rest of the body."⁸

One of the "whole health" messages being promoted by the “Watch Your Mouth” campaign in Washington State-a campaign to raise awareness about the importance of children’s oral health-is: Sealants and fluorides are as important in protecting against disease as immunizations.⁹

The knowledge gap

While pediatricians agree they should become more involved in oral health assessment and care and regularly express their willingness to do so in surveys, one of the key barriers remains insufficient preparation to do so.

Results from a national survey by AAP revealed that “90% of pediatricians said that they should examine the patient’s teeth for caries and educate families about preventive oral health. However, in practice, only 54% of pediatricians reported examining the teeth of more than half of their 0- to 3-year-old patients and only 4% of pediatricians regularly applied fluoride varnish.”⁴

Fully 41% of survey respondents cited their lack of training on how to correctly perform screening dental examinations on young children and to educate families on preventive oral health as the most common barrier to their participation in oral health-related activities.¹⁰ Fewer than 25% reported having received oral health education in medical school, residency, or continuing education.

While researchers in one study suggested that risk-based prioritization of dental referrals during well-child visits might improve dental access for infants and toddlers, they found pediatricians’ referral rates to pediatric dentists when the children had disease, or were at elevated risk for caries, was low.¹¹

However, there are forces at work that might result in more pediatricians including oral health in their well-child visits. Among those are increasing reimbursement and demand for oral health services, as well as studies indicating that what pediatricians do actually helps. When researchers studied the results of “Into the Mouths of Babes,” a medical office-based preventive oral health program, they found children who received 4 or more physician-conducted oral health exams by age 3 years were less likely to be hospitalized for dental caries by their sixth birthdays.¹²

While the specifics of its delivery model remain unclear, the Affordable Care Act promises to put increasing emphasis on the roles of pediatricians on children’s oral health. According to a White House document, the Pediatric Benefit Package includes oral and vision coverage for all children.¹³
 

Dr. Talib

Nasreen Talib, MD, MPH, professor of pediatrics, University of Missouri Kansas City School of Medicine, says pediatricians should conduct oral health risk assessments for all children after 6 months of age or at first tooth eruption. Talib says it’s important to ask parents or family caregivers about their oral health as well. Babies' bacteria that lead to dental decay are passed from the parent to the child, often by sharing utensils or food, she says.

Who is at high risk?

There are certain at-risk groups to which pediatricians should pay special attention, says Charlotte W. Lewis, MD, MPH, associate professor of pediatrics, University of Washington School of Medicine. According to Lewis, whose research for the last 15 years has focused on addressing oral health issues in children, low-income

children tend to experience more complications from dental disease, including toothaches and abscesses that can lead to more serious problems, and have the most difficulty accessing professional dental care, she says.

“Certain children with special health care needs (CSHCN) also need more attention to oral health,” Lewis says. These include kids whose conditions directly impact their susceptibility to caries or increase their risk for complications of oral, or dental, disease (eg, cleft lip and palate, congenital heart disease). CSHCN also includes those whose condition makes it difficult to practice regular oral hygiene or obtain professional dental care, such as those with autistic spectrum disorder with sensory or behavioral challenges and spastic cerebral palsy.

In some cases, the pediatrician will determine other children are at high risk during the history taking. One example, children who go to bed with their bottles are at higher risk for dental issues, Talib says. It’s also good to ask new moms if they’re breastfeeding throughout the night. “If so, there is exposure to the teeth from carbohydrates that can cause problems,.”.

Other children at risk for dental issues include children who take medications that cause mouth dryness, according to Talib. “Saliva is a protective factor,” she notes.

What to do to help high-risk kids

Dr. LewisChildren at high risk for oral health issues, according to Lewis, should begin an intensive caries primary prevention program during the first year of life. The program includes: 1) having parents begin brushing with fluoride toothpaste (rice-grain–size) twice daily at first tooth eruption; 2) twice-yearly fluoride varnish painted onto the teeth with application beginning at first tooth eruption; 3) an oral screening examination at every visit for detection of early signs of dental decay or other oral or dental problems; and 4) oral health anticipatory guidance provided at all well-child visits.

“Based on evidence-based recommendations, there is no longer a place for using fluoride drops in children who live in nonfluoridated communities," Lewis says, "[as] evidence about the effectiveness of fluoride toothpaste in preventing caries is so overwhelming." Evidence is not as clear about optimal care for children who are not considered at high-risk for caries, according to Lewis.

“There is some evidence to support that all children should begin brushing with a rice-grain–size of fluoride toothpaste at first tooth eruption,” Lewis says. “There is not a strong body of evidence to support fluoride varnish in low-caries–risk children.”

Anticipatory guidance for all

These elements of anticipatory guidance apply to all children, according to Lewis:

• Discuss the importance and benefits of drinking fluoridated water (0.7 ppm of fluoride is the recommended level for community water fluoridation).
• Discuss the importance of and benefits of twice-daily toothbrushing with fluoride toothpaste.
• “If only a rice-grain amount is used, it doesn’t matter that a child will swallow some of it because they don’t yet know how to spit out the residue,” Lewis says. “There is no benefit to using training, or ‘fluoride-free,’ toothpaste.”
• Beyond the age of 2 to 3 years, children should brush twice daily with a small pea-size amount of fluoride toothpaste.
• Recommend patients avoid frequent exposure to sweets and sweetened beverages, including 100% juice, and warn parents that they should never let a child take a juice or other sugar-sweetened beverage–containing sippy cup or bottle to bed.
• “To make that more practical, one could say 3 healthy meals and 2 to 3 healthy snacks per day and nothing in between,” Lewis says. “Limit juice to less than 4 oz a day. Water [and] milk are beverages of choice.”

Making the referral

Ideally, a child at high risk for caries also should see a dental professional during the first year of life, according to Lewis.

“A direct referral from the pediatrician or other primary medical care provider to a specific dental professional can be very helpful,” she says. “Depending on where a child lives, it may be easy or hard for a low-income . . . infant, toddler, or child with special dental care needs to be able to see a dental professional beginning in the first year of life. In some situations, it can be hard to access dental care for any child under 3 years of age and, particularly so, for low-income children.”

Children should be evaluated by a dental professional for placement of sealants onto their permanent molars when they erupt at about 6 years of age for the first and at 12 years of age for the second permanent molars, Lewis says.

Making this seamless

Remembering to assess for oral health is made easier with an electronic medical record (EMR), according to Talib. She says she has incorporated reminders into her practice EMR, which offers prompts for oral health risk assessment questions.

“I think the most important thing for pediatricians and other primary care providers who care for children to know is that, if you incorporate [basic oral health care] into your well-child–care visit routine, it doesn’t take that much extra time,” Lewis says. “Adopting a new behavior such as incorporating oral health into your routine is challenging for everyone and it takes dedication, planning, and practice. And then, it becomes second nature.”

REFERENCES

1. Harrison L. A gap in the mouth. http://www.medscape.com/viewarticle/808212. Published July 26, 2013. Accessed September 18, 2013.

2. Centers for Disease Control and Prevention (CDC). Oral health: Preventing cavities, gum disease, tooth loss, and oral cancers. At a glance 2011. http://www.cdc.gov/chronicdisease/resources/publications/aag/doh.htm. Updated July 29 2011. Accessed September 18 2013.

3. American Academy of Pediatrics. Children’s oral health. http://www2.aap.org/oralhealth/. Accessed September 18 2013.

4. Talib N. Preventive oral health for primary care providers. Peds Lines. (Missouri Chapter, American Academy of Pediatrics). Spring/Summer 2011;15-16.

5. Saint Louis C. Study ties poor oral health to cancer-causing virus. New York Times. August 21, 2013. http://well.blogs.nytimes.com/2013/08/21/study-ties-poor-oral-hygiene-to-cancer-causing-virus/. Accessed September 18, 2013.

6. Saint Louis C. Oral infections causing more hospitalizations. New York Times. August 30, 2013. http://well.blogs.nytimes.com/2013/08/30/oral-infections-causing-more-hospitalizations/?_r=0]. Accessed September 18, 2013.

7. American Academy of Pediatrics. More state Medicaid programs pay for children’s oral health prevention services in doctors’ offices. http://www2.aap.org/oralhealth/docs/CelebratingOurWins.pdf]. Published January 2013. Accessed September 18 2013.

8. The Face of the Child: Surgeon General’s Workshop and Conference on Children and Oral Health. Proceedings. http://www.nidcr.nih.gov/NR/rdonlyres/ED6FB3B5-CEF4-4175-938D-5049D8A74F66/0/SGR_Conf_Proc.pdf. May 2001. Accessed September 18, 2013.

9. Seattle Children’s. Community programs: oral health. Seattle Children’s Web site. http://www.seattlechildrens.org/classes-community/community-programs/oral-health/. Accessed September 18. 2013.

10. Lewis CW, Boulter S, Keels MA, et al. Oral health and pediatricians: results of a national survey. Acad Pediatr. 2009;9(6):457-461.

11. Long CM, Quiñonez RB, Beil HA, et al. Pediatricians' assessments of caries risk and need for a dental evaluation in preschool aged children. BMC Pediatr. 2012:49.

12. Stearns SC. Rozier RG. Kranz AM, Pahel BT, Quiñonez RB. Cost-effectiveness of preventive oral health care in medical offices for young Medicaid enrollees. Arch Pediatr Adolesc Med. 2012;166(10):945-951.

13. The Affordable Care Act gives parents greater control over their children’s health care. White House Web site. http://www.whitehouse.gov/files/documents/health_reform_for_children.pdf. Accessed September 18. 2013.

14. Norwood KW Jr, Slayton RL; Council on Children With Disabilities; Section on Oral Health. Oral health care for children with developmental disabilities. Pediatrics. 2013;131(3):614-619.

15. Tang SS. Profile of Pediatric Visits. Elk Grove Village, IL: American Academy of Pediatrics; 2010.

16. Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project. Nationwide Emergency Department Sample, 2009.

17. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General [Executive Summary]; 2000.

18. US Department of Health and Human Services. Annual EPSDT Participation Report: Form CMS-416; 2011.

19. Pew Center on the States. A costly dental destination: Hospital care means states pay dearly. http://www.pewstates.org/search?terms=Medicaid+reimbursement+preventive+dental+care+328928. February 2012. Accessed Septber 19, 2013.

20. Onikul R, Talib N. Preventive oral health and fluoride varnish. Presented at: Workshop Clinical Advances in Pediatrics. Kansas City, MO; 2009. Accessed September 19, 2013.

Reimbursement wins

More and more state Medicaid programs are reimbursing pediatricians for services related to oral care.

According to the American Academy of Pediatrics (AAP), pediatricians and family physicians bill Medicaid programs using standard Current Dental Terminology (CDT) codes. Most states pay providers to apply fluoride varnish, while others also include a separate payment for an oral exam and caregiver counseling.

“In addition to the 44 states that currently cover essential preventive oral health care services, several are expected to add the service in 2013-14. Advocates in Delaware have worked with the state’s Medicaid program to find resources for this policy in the 2013 budget. New Hampshire has bundled these services into the well-child visit as of July 1, 2013. The District of Columbia is actively pursuing paying both dental and non-dental professionals in its 2014 budget. Arizona, Arkansas, Hawaii, and Indiana continue to work through fiscal and political challenges,” according to AAP.

American Academy of Pediatrics. More state Medicaid programs pay for children’s oral health prevention services in doctors’ offices. http://www2.aap.org/oralhealth/docs/CelebratingOurWins.pdf]. Published January 2013. Accessed September 19, 2013.

MS HILTON is a medical writer in Boca Raton, Florida. She has nothing to disclose in regard to affiliations with or financial interests in any organizations that may have an interest in any part of this article.

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