Pediatricians are the gatekeepers of children’s oral health

At some point in the evolution of caring for people, care for our teeth and gums was separated from care for the rest of the body. As far back as the 5th century BC, both doctors and barbers served as the first early dental providers. As the practice of dentistry advanced with the development of technical devices (such as the bow drill and tooth extractor), the field gradually drifted away from medicine and into its own specialty.

As a consequence, for centuries medical doctors have taken care of people’s physical health but have skipped over their teeth and headed straight to the back of the throat. That is largely how I practiced medicine until I learned about how important the teeth and gums are to our overall health. I then began to realize that if I examined the entire mouth, many of my patients had cavities more than any other problem-even more than obesity or asthma-and more of my youngest patients were receiving general anesthesia for dental restorations than for any other reason.

Caries is the most common chronic health condition of children-5 times more common than asthma¹-and is largely preventable. Given that all our patients have mouths (and most have teeth, too!), it only makes sense for medical providers to play a part in promoting oral health.

Physicians are now beginning to understand that having good health also includes having good oral health. The 2011 Institute of Medicine Advancing Oral Health in America report, written largely by our dental colleagues (but chaired by a pediatrician), asked for our help in promoting oral health.² The researchers emphasized the importance of preventive dental care as a strategy to reduce the incidence of dental conditions that patients, especially the underserved, can’t easily get treated once developed-conditions such as cavities and periodontal disease. Even for well-served children, prevention is preferable to “drill and fill.” The report recognized the critical dental workforce shortage and the need to expand the provision of dental services outside the traditional dental office setting.

Pediatricians and other medical providers who care for children are well situated to optimize the oral health of their patients, thereby improving their overall health. Primary care providers are experts at screening for health problems and providing preventive services-that’s what we do. We have the advantage of having many opportunities at well-child care and sick visits to get to know our patients and provide them with care. While it is rare for a child not to have ever seen a medical provider, 2008 data show that over 4 million US children have never received dental care, largely because they could not afford it.³

Our patients are best served if we incorporate oral health preventive strategies in our usual care. Patients should learn to expect this from us just as they expect us to provide them with immunizations and other preventive measures. Strategies could include the delivery of oral health anticipatory guidance and the application of fluoride varnish to high-risk children during a medical visit; co-location of dental hygienists into our practices; or the establishment of real, functional, and operational relationships with our communities’ dental providers. Regardless of the strategies employed, primary care providers are perfectly positioned to teach our students, residents, and families that oral health is integral to overall health.

Pioneering oral health promotion programs, such as Into the Mouths of Babes in North Carolina, Access to Baby and Child Dentistry in Washington State, and the Cavity Free at Three program in Colorado, serve as examples of the benefits of oral health interventions. In these states, where efforts and resources have been dedicated to the oral health of their populations, children are benefiting and receiving more dental services from medical providers as well as dental providers.^4,5 As a consequence, these children are having fewer teeth drilled and filled.⁶ Perhaps the increasing involvement of medical providers in reducing oral health disparities has begun to foster ongoing, collaborative relationships between physicians and our dental colleagues.

As a busy pediatrician myself, I understand the pressures that are placed upon us each day to see more patients and pack more into a visit. When my colleagues ask me how I have time to fit oral health into the spectrum of care I provide, I remind them that we have been providing oral health anticipatory guidance all along. We have long asked what children eat, if they sleep with a bottle, if they brush their teeth. Now, when I ask these questions, I not only provide parents with guidance on how best to provide optimal health for their children but I also include oral health in the discussion. This takes minimally more time.

Assessing a child’s risk for dental problems isn’t much different than how we assess risk for injuries (eg, Do you use a car seat?) or other preventable problems. I apply fluoride varnish to my patients’ teeth depending on their risk for caries. Having streamlined our office processes and procedures and optimized what each member of my health care team does, the time it takes to apply the fluoride is minimal. Now my patients have come to expect this care from me. They tell me that they don’t want their kids to have dental disease and the pain associated with it. They tell me it scares them to have their child go to the operating room to have his or her dental disease repaired. They also tell me that they are embarrassed when their child has a smile filled with bad teeth. It’s time we empower our families to expect us to provide them with the best care possible, and that includes attention to their oral health.

If you have already started to incorporate preventive oral health measures into the care you provide to your patients, kudos to you. If you haven’t yet but are thinking about it, contact your American Academy of Pediatrics Chapter Oral Health Advocate (http://www2.aap.org/oralhealth/COHA.html) who can help you begin. If you haven’t thought about the oral health of your patients, now is the time.

Harnessing the collective efforts of the various providers who treat young children is a strategy that has the potential not only to produce favorable oral health outcomes for the children we serve, but also to greatly improve our patients' overall health and well-being.

REFERENCES

1. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000. Available at: http://www.surgeongeneral.gov/library/reports/oralhealth/. Accessed September 16, 2013.

2. Institiute of Medicine. Advancing Oral Health in America. Washington, DC: National Academies Press; 2011. Available at: http://books.nap.edu/openbook.php?record_id=13086. Accessed September 16, 2013.

3. Institute of Medicine, National Research Council. Improving Access to Oral Health Care for Vulnerable and Underserved Populations. Washington, DC: National Academies Press; 2011. Available at: http://www.nap.edu/catalog.php?record_id=13116. Accessed September 18, 2013.

4. Lewis C, Teeple E, Robertson A, Williams A. Preventive dental care for young, Medicaid-insured children in Washington state. Pediatrics. 2009;124(1):e120-e127.

5. Rozier RG, Stearns SC, Pahel BT, Quinonez RB, Park J. How a North Carolina program boosted preventive oral health services for low-income children. Health Aff (Millwood). 2010;29(12):2278-2285.

6. Pahel BT, Rozier RG, Stearns SC, Quinonez RB. Effectiveness of preventive dental treatments by physicians for young Medicaid enrollees. Pediatrics. 2011;127(3):e682-e689.

DR BRAUNDR BRAUN is associate professor of pediatrics and family medicine and clinical associate professor of dental medicine, Department of Pediatrics, Denver Health and Hospitals, University of Colorado Anschutz Medical Center, Denver. 

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