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Oral health in children—Overlooked and undertreated

Tooth decay is epidemic among young children in this country, yet millions do not receive proper care—or even attention. The authors explain what you can do to help.

Pilar Berg; David Coniglio, MPA, PA-C

Pilar Berg is a student in the PA program at Duke University, Durham, NC. David Coniglio is Assistant Clinical Professor, Duke University Physician Assistant Program. The authors have indicated no relationships to disclose relating to the content of this article.

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Tooth decay is the most common chronic disease of childhood, affecting 5 to 8 times as many children as asthma does.¹ It is also one of the most undertreated conditions in pediatric patients. In fact, dental care has been identified as the most prevalent unmet health need among children in the United States.¹ Low-income and minority children are at greatest risk of having inadequate access to dental care and poor oral health.^1-6 Untreated dental caries have been associated with failure to thrive as well as with a variety of potentially serious medical complications. Poor dental health also adversely affects children’s performance in school.^3,4 Missed class time is an immediate problem, but the overall impact on learning and academic performance brought on by a general failure to thrive must also be taken into account.

Factors contributing to inadequate access to care include geographic maldistribution of clinicians, a shortage of pediatric dentists, difficulties in reaching culturally diverse populations, and individual knowledge and attitudes on the part of both patients and providers concerning oral health.^1-6 Another factor contributing to health disparities is the separation of dental and medical education systems.^5,6 Many health providers outside of dentistry do not receive adequate training in oral health care. Eliminating disparities will require the collaboration of academic, community, and policy leaders to integrate oral health into overall health care.

A “silent epidemic” of oral disease

Oral Health in America, a report issued by the Surgeon General in 2000, described a “silent epidemic” of oral disease in this country. In particular, the report documented profound disparities in the delivery of oral health care to children.¹ Despite overall improvement in children’s oral health resulting from fluoridation of community water supplies and the wide availability of fluoridated toothpaste, a significant number of children continue to suffer from poor dentition. Most of these children are economically disadvantaged and members of ethnic minorities.

Tooth decay is the most common chronic disease of childhood; an estimated 50% to 80% of children will develop detectable dental caries by late adolescence.^1-3,6 Poor oral health has a direct effect on a child’s school performance. One study documented a significant loss of school time due to poor oral health among females, Hispanic students, and those with lower income or no health insurance.⁴

In some pediatric patients, untreated dental caries has been associated with failure to thrive. Caries also provides a reservoir of contamination contributing to abscess formation, cellulitis, and systemic spread of disease (see Figure 1). These conditions lead a substantial number of children with untreated caries to be seen in emergency departments for their first dental visit.⁷

The degree of advanced decay in many of these children may lead to a variety of dental procedures, often requiring general anesthesia and support with IV antibiotics. Decay in primary dentition is a known predictor of decay in permanent teeth; and as poor oral health and dental disease often continue into adulthood, they have the potential to adversely affect speech, nutrition, economic productivity, and quality of life.³

Oral infection is also an established risk factor for comorbid conditions and related complications in susceptible patients. Pregnant women, for example, may face risks of preterm labor and low birth weight for their children. Gram-negative periodontal infection is thought to be the underlying cause, leading to premature labor or rupture of membranes. Documented periodontal disease is also believed to increase the risk of cardiovascular disease and stroke; the infection may contribute to vessel wall inflammation in the at-risk cardiac patient, triggering microthrombus formation and the development of atherosclerosis.³

Childhood oral disease, with all of its significant consequences for health and well-being, may not be appreciated by the child’s primary health care provider for a number of reasons, including a lack of training in recognition of oral health problems. This may occur because of the separation of professional training in medicine and in dentistry, as most medical and dental schools are not affiliated with each other.⁶

Factors affecting access to dental care

Disparities in children’s access to oral health care arise from a variety of factors.

Not enough dentists There is a geographic maldistribution of dental clinicians, complicated by inadequate numbers of dentists treating Medicaid-eligible children.⁵ Only 10% of dentists participate nationwide in Medicaid reimbursement programs, and pediatric dentists are relatively few in number.^3,5

Cultural factors As the Surgeon General’s report noted, ethnic minorities and people who are economically disadvantaged suffer a disproportionate burden of oral disease. For the health care provider, cultural sensitivity and cultural competency are necessary to establish a foundation for improving oral health outcomes in these populations. This requires awareness of individual patient preferences. Patients who do not perceive oral health as a priority may not try to overcome barriers such as poor access to care; thus, providers need to emphasize the importance of oral health and work with patients and families to develop individualized plans for overcoming those barriers. Principles of self-awareness, respect for diversity, and sensitivity in communication are important for the provider who is evaluating or treating oral health problems in the pediatric patient.¹

Economic factors At all ages, the prevalence and severity of childhood tooth decay can be linked to socioeconomic status; black and Hispanic children are disproportionately affected by caries.³ Poor oral health and lack of dental care are most evident among low-income preschool children, who are more likely to have cavities than are higher-income children.⁶ Children who are Medicaid-eligible and have cavities have twice the number of decayed teeth and twice the number of visits for pain relief, but fewer total dental visits, than do children in families with higher incomes.⁶ Decayed teeth in children from lower-income households are more likely to remain untreated at all ages.³

Dental care is more likely to be sought by those with medical or dental insurance; for every child who does not have medical insurance coverage, there are 2.6 children who lack dental insurance coverage.³ Despite having access to dental insurance through Medicaid or similar programs, few children receive preventive dental care, perhaps because of the low number of dentists participating in Medicaid.⁵ For near-poor families who do not qualify for Medicaid or the State Children’s Health Insurance Program (SCHIP), access to oral health care may be limited by factors such as lack of access to dental insurance or exclusion of dental-related conditions from definitions of medical necessity in standard medical insurance policies.³

Preventive strategies that target children early in the process of tooth formation and learning eating habits may promote better oral health. Most infants and young children will be seen frequently by a primary health care provider in the first 2 years, creating ample opportunity to promote oral health regardless of the family’s economic status.⁵

Dietary factors Personal health habits in children develop as a result of in-home teaching from parents or caregivers and under the influence of cultural and social factors.¹ For instance, high-risk diet or feeding practices, such as pre-chewing children’s food or high consumption of acids or sweet snacks, can be harmful to teeth because the bacteria colonizing the mouth adhere to tooth surfaces. These bacteria are able to ferment sugars and other carbohydrates to form lactic and other acids. Repeated cycles of acid generation can result in the microscopic dissolution of minerals in tooth enamel and the formation of an opaque white or brown spot under the enamel surface (see Figure 2). Frequency of carbohydrate consumption and physical characteristics of food (stickiness, for example) also play a role.

Recommendations for screening and early intervention

Screening recommendations for pediatric oral health come from the United States Preventive Services Task Force (USPSTF), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP). The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation at recommended doses to preschool children older than 6 months if they live in an area where the principal water supply has an inadequate amount of fluoride. This is a USPSTF category B rating, indicating that the Task Force found fair evidence that supplementation in this setting could help reduce dental caries.⁸ The AAFP recommendation is similar.⁹ The AAP recommendations are more general, calling for all persons to drink water with an optimal fluoride concentration and to brush regularly with fluoride toothpaste, adding that persons at high risk for dental caries might need additional fluoridation measures.¹⁰

The American Dental Association (ADA) recommends a first dental evaluation within 6 months of the eruption of the first tooth and no later than at 12 months of age.¹¹ The ADA also recommends oral health education based on the child’s developmental needs and advises limiting dietary sugar intake, restricting consumption of beverages containing fermentable carbohydrates, and teaching oral health techniques to parents before the child’s first tooth erupts.¹¹

Prevention and treatment measures

The approach to prevention of childhood tooth decay includes the community, the health or dental care provider, and the patient. At the community level, water fluoridation has greatly decreased the incidence of dental caries. Because community-provided water fluoridation is not universal, efforts must continue to increase its availability. An estimated 65% of communities have fluoridated water systems.^1,3,12 Lack of fluoridation may disproportionately affect poor and minority children, who are less likely to receive other preventive interventions, increasing morbidity and the costs of care.³ Community health awareness campaigns may also play a role in increasing public recognition of the problem.

Because water fluoridation does not provide complete protection, professionally applied topical fluorides and dental sealants are also needed. At an appropriate age, usually considered to be the age at which children can be taught not to swallow, parents and children should be encouraged to use fluoride toothpastes to brush teeth at home. At all times, proper infant feeding practices and good nutrition are necessary to promote oral health (see “What primary care providers can do to promote better oral health”).

Education in oral health and hygiene and promotion of access to dental care can be advocated in schools. Advocacy issues also include increasing dental care providers’ acceptance of Medicaid and SCHIP patients, encouraging enrollment in SCHIP, and decreasing transportation barriers to health facilities in rural areas.²

Toward better oral health education for providers

Because medical and dental schools are not often in the same facilities and because the curricula are not shared, gaps may occur in the education of health professionals. Family care providers may not screen for oral diseases such as caries, periodontal disease, or oral cancer because they have not received much—if any—oral health education.³ When this is the case, patients who are at highest risk for oral disease and dental care access problems will be affected disproportionately.³

Educating primary health care providers to screen for oral health problems is important for a number of reasons. Since well-child visits start at infancy and continue throughout the first 2 years of life, the primary care provider can serve as the immediate source of education, prevention, and timely referral in this critical period of early child development.¹ Almost 90% of poor children have a usual source of medical care, and 74% of poor children 19 to 35 months of age receive all their vaccines. By contrast, however, only about 22% of children younger than 6 years receive dental care.¹

Another rationale for training nondental health professionals in oral health promotion is the shortage of dental professionals available to treat underserved populations. A declining number of dentists per capita has accentuated the difficulty disadvantaged groups experience in accessing dental care. Training medical providers to promote oral health will allow earlier detection of oral disease; training programs have been shown to enhance the primary care clinician’s ability to recognize oral disease and to make timely referrals to dentists.^3,13

A model program for training primary care medical providers in North Carolina is teaching providers to perform oral health risk assessment, provide guidance to families, apply fluoride varnish, and refer Medicaid-eligible children (up to 3 years of age) to dentists. Information about this voluntary statewide program, known as “Into the Mouths of Babes,” is available from the North Carolina Academy of Family Physicians (NCAFP) (www.ncafp.com).

What can be done

Efforts to eliminate disparities in oral health care will require collaboration at many levels: academic, community, and individual. Greater integration of academic dentistry with medicine and other health professions makes increasing sense. Primary care training programs, including PA curricula, place varying amounts of emphasis on oral health care screening and treatment. Models exist in the health care system for training primary care clinicians in screening, treatment, and referral of pediatric patients with dental problems. The NCAFP offers one such model. Primary care providers may wish to check with local and state medical and dental societies to see if similar programs are available in their areas.

Primary care providers are in an optimal position to see infants and children on a regular basis. Well-baby and well-child checks should include oral examinations and patient education about oral health. Providers can offer samples of dental care products, when available, to economically disadvantaged patients. Primary care clinicians should also avail themselves of continuing medical education materials and activities imparting current, evidence-based concepts of oral health care.

Another key step is to improve reimbursement, through Medicaid or other programs, for procedures related to oral health. This may offer incentives for more providers to accept patients without other insurance coverage into their practices. Further research will be necessary to determine how dental insurance can also be made more affordable and more accessible to more people.

Finally, all providers must continue with efforts to improve their awareness of the societal and cultural barriers that minority and disadvantaged patients face in the health care arena. Sensitivity to cultural concerns, a nonjudgmental approach to the patient, and persistence in maintaining cultural competency are essential elements of clinical practice. As skilled practitioners of this aspect of the art of medicine, PAs should continue to be advocates for the oral health and well-being of their patients. •

REFERENCES
1.
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American Dental Association. ADA Statement on early childhood caries. Available at: http://
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