How pediatricians can tackle oral healthcare

Fewer than 2% of 1-year-olds see a dentist as recommended by the American Academy of Pediatric Dentistry (AAPD) despite climbing prevalence of dental caries in early childhood. Pediatricians are positioned to catch dental problems early and offer interventions when dentistry is not provided or not an option for some children.

According to AAPD, 60% of parents believe their children should see a dentist by age 1 year, but only 25% actually brought their children to the dentist.

To combat rising cases of dental caries in children over the last few decades, dental and pediatric experts are recommending increased interventions, including a new recommendation that children receive fluoride treatments as early as 6 months when their water supply does not contain sufficient fluoride-the Centers for Disease Control and Prevention (CDC) says 67% of US households receive water with adequate fluoride levels.

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The recommendation is part of a broader plan for prevention of dental caries released by the US Preventive Services Task Force (USPSTF). The agency says there is insufficient evidence to support routine screenings of dental caries prior to age 5 years, but recommends that primary care clinicians such as pediatricians apply fluoride varnish to the teeth of all infants and children starting at the age of primary tooth eruption.

Prevalence of dental caries declined from the 1970s until the mid-1990s when it began to increase, reaching 42% in children aged 2 to 11 years by 2004. The National Health and Nutrition Examination Survey (NHANES) found significant increases in the 2- to 5-year-old population, although those numbers have been declining since interventions were enacted as part of the Healthy People 2010 initiative.

Reducing the number of 3- to 5-year-old children with dental caries continues to be a goal under the Healthy People 2020 initiative, with a baseline of 33.3% of children in that age group having dental caries in at least 1 primary tooth as of 2004. The goal is to reduce that number to 30%, and the US Department of Health and Human Services says prevalence of dental caries in this age group was 27.9% as of 2012.

Despite improvements in prevalence, the USPSTF says dental caries remains the most common chronic disease in children, even outpacing asthma. Caries can result in pain and loss of teeth as well as impaired growth and weight gain, poor self-esteem, speech problems, and reduced school performance-The USPSTF attributes a loss of more than 54 million school hours each year to dental problems.

A 2010 report on utilization of early dental care indicates that children should first visit the dentist by 1 year of age. However, most children (51.9%) don’t have their first visit with a dentist until ages 3 to 6 years, with only 1.73% of children aged 1 year or younger visiting a dentist. The report also notes that by the time most children (59.86%) visit the dentist between the ages of 3 and 6 years, it’s due to complications such as caries rather than preventive care.

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Recommendations for care can be confusing for parents, notes the study. Although pediatric dentists recommend children begin seeing a dentist when the first tooth emerges or by age 1 year-with follow-up appointments every 6 months-only 17.93% of general dentists share this recommendation. Nearly 40% recommend the first dental visit should occur between 1 and 2 years of age, and 31% recommend children first visit the dentist between ages 2 and 3 years, according to the report.

The CDC reports that 83% of children aged 2 to 17 years visited a dentist at least once in 2012, and only about half of pediatricians examine the teeth of their patients aged 0 to 3 years.

In a 2009 national survey, 90% of pediatricians acknowledged that they should examine patients’ teeth for caries and offer parents education on preventive care, but only 54% of pediatricians say they carry out assessments and education in more than half of their patients aged under age 3 years.

Lack of training was cited as the most common barrier to optimal practice, and less than 25% of pediatricians say they were educated on oral health during the course of their medical training. For pediatricians that refer patients suffering from caries or are at-risk of dental problems, 74% say the availability of dentists that accept Medicaid for children aged under 3 years posed a “severe barrier.”

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Paul Casamassimo, DDS, MS, of Nationwide Children’s Hospital and a professor of pediatric dentistry at The Ohio State University College of Dentistry, says pediatricians are the first line of oral healthcare for children due to the frequency of their early well-child visits.

“Well before parents consider a first dental visit for their child, the pediatrician has seen the child several times. This periodicity opportunity offers parents a first oral health anticipatory guidance experience,” says Casamassimo. “Infant oral health in the pediatrician’s office still remains out of the mainstream due to practice patterns, other perceived health needs of families with young children, lack of oral health instruction in medical education, and reimbursement issues.”

Medicaid reimbursement for fluoride varnish applications range from $9 to $53, according to USPSTF.

Socioeconomic status, insurance coverage, and race all have effects on dental care beyond the pediatric practice, according to multiple reports.

Nearly 18% of children aged 5 to 19 years had untreated dental caries as of 2012, according to the CDC. Of those children aged 3 to 5 years with dental caries as of 2012, 16.9% carried private insurance; 38.7% had public insurance; and 32.2% were uninsured. Almost half-49.3%-had family income levels below 100% of the federal poverty level. Another 23.4% were at 100-199% of the federal poverty level, and 17.2% were at 200-399% of the federal poverty level. Hispanic children accounted for 38.3% of caries cases in the 3-to-5 years age group; blacks accounted for 42%; and whites accounted for 20.6%.

Additionally, 73% of preschoolers and 48% of school-age children with dental caries have unfilled cavities, and 60% of low-income children have untreated dental problems compared to 46% of children in higher income households. Dental care utilization by income level reveals extended disparities, with 30.8% of poor children; 33.9% of low-income children; 46.5% of middle-income children; and 61.8% of high-income children visiting the dentist at least once over a year.

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Minority children also face higher acuity-60% of Hispanic children and 64% of black children have unfilled cavities compared with 50% of white children. Permanent tooth decay left untreated occurs in 45% of black children, 41% of Hispanic children, and 30% of white children. One-third of minority children visit the dentist once each year compared with half of white children, and children of parents with less than a high school education were less than half as likely to visit a dentist than children whose parents are college graduates, according to a 2009 report.

The CDC recommends that clinicians educate all parents about the use of fluoridated toothpastes and fluoride supplements at well-child visits. Pediatric offices are a good place to start education on dental health, considering the Medical Expenditure Panel Survey estimates that 89% of infants and 1-year-olds visit physicians annually, compared to just 1.5% that visit dentists.

The American Academy of Pediatrics (AAP) recommends that pediatricians advise parents to use fluoride toothpastes beginning with the eruption of the first tooth, using a minimal rice-grain sized amount in children aged under 3 years, and a pea-sized amount in children aged over 3 years. Young children should also not receive water to rinse after brushing, since their instinct will be to swallow.

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Like the USPSTF, AAP recommends fluoride varnish be applied at least every 6 months, but preferably every 3 months once the first tooth erupts until the child begins to visit a dentist. To apply fluoride varnish, teeth are dried using a 2-inch gauze square, and the varnish is then painted onto all surfaces of the teeth, with a brush provided with the varnish. Parents are advised to have children eat soft foods and not brush their teeth on the night of the varnish application to maximize contact time, with twice daily brushing resuming the following day.

Fluoride varnish was only applied in about 4% of primary care practices as of 2009. The USPSTF says the intervention is practical for practices to implement since it does not require special equipment or personnel, and takes little time. Minimal training may be required, but in many states, nurses or medical assistants may be able to perform the procedure, according to USPSTF. The AAP offers guidance on applying fluoride varnish, as well as information about materials, training requirements and billing codes. Additional resources can also be found through the National Interprofessional Initiative on Oral Health.

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The AAP also recommends that pediatricians be well-versed in the assessment of caries risk, assessing a child’s fluoride exposure to weigh the need for topical or systemic supplements, understanding how to apply fluoride varnish, and advocating for water fluoridation in their local communities.

Additionally, the American Dental Association recommends wiping infants’ teeth with a wet cloth until they are comfortable brushing their child’s teeth in the traditional manner.

In addition to regular assessment and education, pediatricians should make sure children are weaned from bottles at an appropriate age; check teeth for caries during physical assessments; advise parents on teeth brushing; and assess a child’s exposure to fluoride, says Casamassimo.

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“Wean-Screen-Clean-and-Fluorine should be the preventive mantra of the pediatrician seeing young children,” he says. “One last important intervention is to refer the child to a dentist who is willing to see young children. The establishment of a dental home, early, has been and continues to be associated with reduced dental caries and less expense for families.”

Casamassimo says pediatricians who don’t already offer fluoride varnish treatments should embrace the intervention.

“Fluoride varnish has been shown to reduce dental caries in children. In studies, multiple applications during the well-child sequence, are associated with a reduction in early childhood caries,” Casamassimo says. “Resistance to therapeutic applications of fluoride varnish, use of home fluoride toothpaste, or consumption of fluoridated water is not uncommon. Safety of fluoride is well established, so its use is both effective and safe for children. Ironically, fluoride is ubiquitous in the environment, so even the most resistant and cautious parent should be advised that fluoride is present in natural and processed foodstuffs, so avoidance of some exposure is almost impossible.”

Casamassimo says pediatricians who encounter parents’ resistance to fluoride treatments may have to use unconventional tactics to educate them on the consequences of inaction.

“Professional organizations have graphic illustrations of advanced dental caries which may motivate parents,” Casamassimo says. “Any treatment of dental caries in very young children is difficult and parents can be advised that once dental caries occurs, it can’t be reversed, can progress to a level that affects general health and learning, and will require often serious behavioral interventions for treatment such as sedation or general anesthesia.”