Oral Health:

The American Academy of Pediatricians (AAP) holds that pediatricians are responsible for oral health supervision of children younger than 3 years. How can I do a credible job of this in a busy office practice?

----MD

This is an excellent question--and one that is extremely important in a world of increasing responsibilities for pediatricians and limited time with patients. The answer to the question boils down to 4 things: educating yourself, incorporating the information and skills into your practice, empowering families, and connecting with dental colleagues.

Educating yourself. The primary oral health issue that affects children in this age group is dental caries--a multifactorial disease process that is entirely preventable. The multifactorial nature of dental caries presents multiple opportunities and avenues for prevention. Take the time to educate yourself on the cause, pathophysiology, and prevention strategies of this common disease. Numerous educational resources exist, including one from the AAP's Oral Health Initiative. The Web site is http://www.aap.org/commpeds/dochs/ oralhealth/index.cfm.

Incorporating into practice. Despite the time constraints of a busy practice, pediatricians can do a credible job of oral health supervision for this age group in 3 ways: risk assessment, physical examination, and anticipatory guidance. An assessment of the risk for dental caries can be accomplished with a few questions about access to fluoride (water, toothpaste, and other sources), dental hygiene practices (brushing), diet (nothing new, we already ask about bottle weaning, sugar intake), sibling/ caregiver experience with caries (another child or mom with lots of dental work), and access to a dentist. These questions can be asked by any member of the office team, answered by the parent on a form while waiting, or posed in any other way, with red flags addressed in the exam room.

Since we already examine the pharynx, a focused assessment of the teeth (not many in our youngest patients and up to 20 in our 3 year olds) adds little time. Looking for plaque, white spot lesions, and cavitation at the gumline of teeth and viewing the molars for any abnormalities requires only a good look, a good light source, and a few seconds. With information from the risk assessment and physical examination, focused age-appropriate anticipatory guidance can address issues of fluoride access, dental hygiene, diet, and the importance of oral health and the primary teeth. This information can be given by the pediatrician or office staff or via handouts--or a combination of them all.

Empowering families. Ideally, the pediatrician and the family work as a team to maintain and improve a child's health. The same is true for oral health. Delivering messages of the importance of oral health, letting families know they can prevent tooth decay in their children, encouraging families to be alert for the same tooth changes you look for in your exam, and answering their questions about how to improve their child's oral health will result in better outcomes. An empowered family will make your job easier.

Connecting with dental colleagues. Communicating, collaborating, and connecting the medical home with the dental home is an important part of protecting the oral health of children. Like any other member of the pediatric health team (eg, cardiologist or pulmonologist), we must share responsibility for our patients' health. Assisting families in gaining access to dentists and conscientiously following up on oral health problems in our patients will improve their overall health, not just their oral health. Often, finding a dentist for our patients is difficult, but building a relationship with a local dentist is a first step in increasing access to care.

----David M. Krol, MD, MPH
Chair, Department of Pediatrics
University of Toledo College of Medicine    

References:

For more information:

Krol DM. Educating pediatricians on oral health: past, present, and future. Pediatrics. 2004;113:e487-e492.
Krol DM. Dental caries, oral health, and pediatricians. Curr Probl Pediatr Adolesc Health Care. 2003;33:253-270.