Oral Health in Primary Care Medicine: Practice and Policy Challenges
Am Fam Physician. 2004 Dec 1;70(11):2074-2076.
In this issue of American Family Physician, Douglass and associates1 provide sound and useful information to address the epidemic of early childhood caries. The authors point out that among low-income preschoolers in the United States, about one in three has dental caries. The problem is even worse in some areas of the country. For example, approximately 40 percent of all preschoolers in Ohio have dental caries. The number of primary dentition dental caries in U.S. children has not declined over the past 30 years.2 Clearly, the policy of recommending that children see a dentist for the first time at three years of age has not worked, and earlier referral, as suggested by Douglass and associates,1 is needed.
Earlier dental referral makes sense. Establishing a home for dental care (a “dental home”) offers patients access to a full range of preventive dental services as well as early intervention, if needed, by a dentist to treat incipient dental caries at minimal cost. Although incontrovertible evidence is lacking on the effectiveness of early intervention by a dentist, support for early intervention is growing among physicians and dentists.
A recent report on children in the North Carolina Medicaid program suggests that those who visit a dentist in the first year or two of life receive more preventive services, require less restorative care, and generate lower care costs as they grow up.3 Children who have a dental home are more likely to receive necessary services.4 Providing pre-natal counseling and addressing the oral health of the mother reduces the child’s risk for caries.5 Perhaps the most compelling rationale for moving the first dental visit to one year of age is that once primary dental caries begins, it is difficult to stop.6
The first dental visit at one year of age typically is devoted to anticipatory guidance for the parents and demonstration of preventive care. An examination is performed, but the teeth rarely are professionally cleaned. Not enough evidence exists to support dental visit periodicity at this age, and for many children, this can be their only visit until they are three years old. The family physician’s role during this period may be to act as a risk-assessment intermediary and to refer to a dentist at-risk children who are seen during well-child visits.
The family physician’s role in oral health may be easier in theory than it is in practice.7 When it comes to counseling, physician education in contemporary oral health remains limited, even within the pediatric community. A recent review of physician involvement in oral health found that where risk-assessment services, preventive counseling, patient referral, and fluoride prescribing are concerned, only the last factor was marginally effective.7
Referral also presents a problem. The results of a recent survey8 indicate that few general dentists see children who are younger than three years. Referral to a pediatric dentist may be a problem because there are only about 5,000 pediatric dentists in the United States. As family physicians gain knowledge of oral health, they will undoubtedly become better at identifying at-risk children and children with dental diseases—a role advocated by the American Academy of Pediatrics (AAP)9—and try to refer more children, which may further their frustration if pediatric dentists are not available.
Fitting oral health in a meaningful way into primary care medicine may be a daunting task. In a recent large-scale AAP study10 of early well-child visits, physicians reported that such visits last about 18 minutes. Many important preventive interventions may not be completed. Furthermore, reimbursement for oral health services provided by physicians is seldom made outside of grant-funded demonstration projects and is mainly provided for application of fluoride varnish. The Centers for Disease Control and Prevention maintains that this use of fluoride is intended for children at high risk for caries who, according to the AAP, should be referred to a dentist.11
To help primary care physicians begin to realize their role in infant oral health as proposed by Douglass and colleagues,1 I add some pragmatic advice:
Physicians should establish relationships with general and pediatric dentists who will see young children, especially children younger than three years.
Physicians should consider their practice population’s risk for dental caries when determining which oral health interventions to incorporate into their care.
Physicians should make oral health an extension of primary care medicine.
Our health care system has failed many children in preventing primary dental caries. Greater involvement and advocacy by family physicians may be one way to address this silent epidemic.
1. Douglass JM, Douglass AB, Silk HJ. A practical guide to infant oral health. Am Fam Physician. 2004;70:2113–22.
2. Edelstein BL, Douglass CW. Dispelling the myth that 50 percent of U.S. schoolchildren have never had a cavity. Public Health Rep. 1995;110:522–30.
3. Savage MF, Lee JY, Kotch JB, Vann WF Jr. Early preventive dental visits: effects on subsequent utilization and costs. Pediatrics. 2004;114:e418–23.
4. United States Public Health Service, Office of the Surgeon General. Oral health in America: a report of the Surgeon General. Rockville, Md.: Dept. of Health and Human Services, U.S. Public Health Service, 2000.
5. Kohler B, Andreen I. Influence of caries-preventive measures in mothers on cariogenic bacteria and caries experience in their children. Arch Oral Biol. 1994;39:907–11.
6. Greenwell AL, Johnsen D, DiSantis TA, Gerstenmaier J, Limbert N. Longitudinal evaluation of caries patterns from the primary to the mixed dentition. Pediatr Dent. 1990;12:278–82.
7. Bader JD, Rozier RG, Lohr KN, Frame PS. Physicians’ roles in preventing dental caries in preschool children: a summary of the evidence for the U.S. Preventive Services Task Force. Am J Prev Med. 2004;26:315–25.
8. Seale NS, Casamassimo PS. Access to dental care for children in the United States: a survey of general practitioners. J Am Dent Assoc. 2003;134:1630–40.
9. Hale KJ, American Academy of Pediatrics Section on Pediatric Dentistry. Oral health risk assessment timing and establishment of the dental home. Pediatrics. 2003;111(5 pt 1):1113–6.
10. Halfon N, Olson LM. Content and quality of health care for young children: results from the 2000 National Survey of Early Childhood Health. Pediatrics. 2004;113(6 suppl):1895–1990.
11. Recommendations for using fluoride to prevent and control dental caries in the United States. Centers for Disease Control and Prevention. MMWR Recomm Rep. 2001;50:RR-14:1–42.
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