In 2000, Surgeon General David Satcher, M.D., Ph.D., called poor oral health in America a “silent epidemic.” He emphasized that oral health is not just about healthy teeth but is integral to general health, and pointed out that safe, effective measures exist for preventing the most common dental diseases—dental caries and periodontal diseases.1 In this issue of American Family Physician, Gonsalves and colleagues discuss the most common oral lesions that physicians encounter and note that differentiating benign from worrisome lesions, and providing appropriate risk-factor counseling, is crucial to the achievement of national oral health goals.2,3
Since the Surgeon General's report, oral health has moved to the forefront of many prevention initiatives. Children's oral health is a particularly important part of this effort. There is now consensus among leading national professional health organizations that the earlier a child receives preventive oral health services, the lesser his or her risk of developing dental disease. The American Academy of Pediatric Dentistry recommendations published in 2000 stated that infants should have an initial oral evaluation within six months of the eruption of the first primary tooth but by no later than one year of age.4 In 2003, the American Academy of Pediatrics joined the dental community by advocating that a dental home be identified for all at-risk infants by one year of age.5 The basis of these policies is that dental caries is an infectious and thus preventable disease.
Early childhood caries, a particularly severe pattern of dental disease affecting infants and toddlers, results in pain, oral dysfunction, and low self-esteem, and often necessitates costly rehabilitation in a hospital setting. Children at risk of developing early childhood caries include those with special health care needs; those with mothers who have a history of multiple caries; those who have a high sugar intake, sleep with a bottle, or have milk in their mouths over a prolonged period; and those whose families are of low socioeconomic status. However, the disease can be prevented by oral risk assessments, anticipatory guidance, and preventive oral health interventions.6
Family physicians are in a unique position to champion oral health and reduce disparities in this area because of their provision of care to children and adults, and especially to childbearing women. Dental interventions aimed at women who are pregnant, such as referral for dental cleaning and education about dental hygiene, can reduce the risks of prematurity and low birth weight.7
In spite of national recommendations, many children have limited access to dental professionals. For every child without health insurance, there are three who lack dental insurance, and the number of dentally uninsured Americans totals more than 100 million.8 Three out of four dentists do not treat patients with Medicaid insurance; many more do not treat those who are uninsured.9 However, during the first few years of life, children visit clinics for well-child examinations and immunizations. These visits are an ideal time to provide screening, anticipatory guidance, and appropriate needs-based referrals so that dentists, who are in more limited supply, can provide the definitive care to those who most need it.
At well-child examinations, health care professionals should “lift the lip” to check for early signs of caries on the top front teeth. Medical charts, whether electronic or paper-based, should have a section to check off when the oral health assessment has been performed as part of a physical examination. Anticipatory guidance should be offered on appropriate feeding and sucking habits, nutrition, weaning, and care of the teeth, including wiping the erupting teeth with gauze or a soft cloth. Health education in this period should include information about the role of primary teeth to dispel myths that “baby teeth” are not important. All education should stress the infectious nature of the disease and be provided in a culturally and linguistically appropriate manner.
The biggest barrier faced by the primary care community in implementing these strategies is time. To help with this, clinics can develop risk assessment tools that would indicate which children and their families need more guidance on this issue. Because of the infectious nature of the disease, children who have siblings with early childhood caries would be obvious candidates.
Collaboration must be built among all disciplines to address this epidemic. In San Diego, Calif., tobacco settlement money was used to create a manual on accessing dental resources for primary care professionals who care for children. Health care professionals should advocate for increased state and federal funds for oral health programs, support community-based oral health education programs, promote water fluoridation projects, and support programs to increase the number of, and payments to, dentists willing to serve low-income families.
The traditional model of oral health care by a solo-practice dentist is not sufficient to combat the silent epidemic of early childhood caries. The preventable nature of tooth decay must be addressed through screening, assessment, and anticipatory guidance at the primary care level. This approach can build collaboration between primary care and dentistry, and can help eliminate oral health disparities.