Commentary
Ending an Epidemic
Physicians’ Role in Primary Caries Prevention
Physicians need to care for a child’s entire body, including the mouth.
By Amos Deinard, M.D., M.P.H., and Brenda Johnson, Ph.D., M.P.H.
“The mouth is part of the body.” With those words, the first-ever Surgeon General’s conference on oral health began in June 2000.1 One focus of the opening presentation was dental caries, which was characterized as a silent epidemic that is disproportionately afflicting children who are covered by government-sponsored health insurance programs (in Minnesota, Medical Assistance and MinnesotaCare) or are from working-poor, uninsured families.2 A major reason for the problem is the short-term difficulty of finding dentists to treat these high-risk children.
Dentists report several reasons for not participating in Medicaid programs including historically low reimbursement rates, a high percentage of missed appointments among Medicaid patients (dental clinics have few walk-ins), burdensome administrative requirements, failure of state programs to communicate with them, and antiquated provider policies and manuals.2,3 A 2008 Government Accountability Office (GAO) report estimated some
20.8 million poor children in the United States are covered by public health insurance programs. The report also estimated that 6.5 million children have untreated tooth decay. One in three children on Medicaid had untreated dental decay, and about one in nine had untreated decay in three or more teeth. In addition, the GAO found that only one in eight children enrolled in public health programs ever sees a dentist, compared with the more than
50 percent of children from families that have commercial insurance.4 Additionally, private practice dentists generally do not offer sliding-fee payment schedules based on family size and income the way federally qualified health centers do for their medical and dental services. Consequently, even children whose parents are working but have no insurance lack access to ongoing prevention and treatment of oral disease.
Dental caries is the most common chronic disease of childhood, five times more common than asthma and seven times more common than hay fever. Children who are poor (those who live in households earning less than 100 percent of the federal poverty guidelines) or who are members of racial/ethic minority groups are affected to a greater extent than children who are Caucasian or who live at or above 300 percent of poverty. Children with untreated dental caries are often in pain and may miss school as a consequence. In 1999, children in the United States missed 51 million hours of school for this reason, and their parents lost 164 million hours of work time as a result.2 Poor oral health can affect a child’s nutrition, overall health, social adjustment, appearance, school performance, and ability to thrive. Premature loss of primary teeth may adversely affect eruption of permanent teeth. Localized infection can spread and become a more generalized problem.
Dental caries is considered an infectious disease caused primarily by bacteria (especially Streptococcus mutans) that are transmitted from caregiver to child through such activities as wetting a pacifier with saliva and prechewing or pretasting food; thus, caries is theoretically preventable. The caries process begins when bacteria residing in plaque metabolize sugars in food and beverages, creating acidic excrement that etches tooth enamel by removing minerals from the tooth (the earliest stage of the caries process). Repeated cycles of bacteria-plus-sugar-equals-acid result in additional loss of minerals, with the end result being a cavity. Left alone, tooth decay will progress through the pulp, allowing bacteria to infect the interior of the tooth, where the nerves and blood supply lie, leading to an abscess. If the infection is not treated, it can infect surrounding tissue, travel to other organs including the brain, and cause death, as it did in the well-publicized case of Deamonte Driver, a 12-year-old who died in 2007 because his homeless mother could not find a dentist to care for his abscessed tooth.5
Fortunately, if the caries process is caught early, it can be reversed by applying fluoride topically. If a child receives one application of fluoride varnish a year, the risk of caries declines by 50 percent; a second application has been shown to reduce the incidence by another 50 percent.6 Currently, the American Dental Association recommends an application of fluoride varnish every three months for children at high risk of tooth decay and every six months for children at moderate risk.7 But if children aren’t seen by a dentist because they lack insurance coverage or access to dental care, where can they get this simple, preventive treatment?
The Doctor’s Role
Primary care medical providers attend to the entire body, rather than a single organ system. Since the mouth is part of the body, we have a responsibility to keep it healthy, especially if a child has no dental home. One opportunity to reduce the risk for caries is for medical providers to take advantage of the well-child examination. Medical providers see children at least 12 times before the age of 5 for well-child care and perhaps many more times to treat illness. Primary caries prevention can be offered during either type of medical encounter. Those visits are opportunities to assess a child’s risk for dental caries and evaluate his or her oral health; teach the parents or caregivers about the causes of caries and how to prevent them; apply fluoride varnish (ordered by and under the general supervision of a nurse practitioner, physician assistant, or physician), a process that takes less than five minutes and can be done by a certified medical assistant or licensed practical nurse; and urge the parent or caregiver to find the child a dental home before his or her first birthday. (The Department of Human Services and health plans will reimburse primary care medical providers for an application of varnish during a well- or ill-child visit.)
A project currently sponsored by Delta Dental, the Medica Foundation, UCare, and the National Children’s Oral Health Foundation and conducted by the University of Minnesota’s Department of Pediatrics is helping family medicine and pediatric clinics integrate primary caries prevention services into well-child visits. The intervention includes a gross oral examination, a 30-second risk assessment, provision of anticipatory guidance for the caregiver about caries etiology and prevention, application of fluoride varnish (based on risk status), and counseling the caregiver about the importance of finding a dental home for the child by 1 year of age. The project provides each clinic with start-up materials, including 100 doses of fluoride varnish, a list of fluoride varnish manufacturers and suppliers, information about how to bill health insurers for varnish applications, a copy of the Atlas of Common Dental Pathology for Primary Care Medical Professionals,8 and print materials to educate medical providers, parents, and ancillary clinic staff about caries etiology and prevention. Providers are urged to instruct the caregiver to call the child’s health plan or the Department of Human Services to learn how to secure a dental appointment.
The goal of the project is to encourage clinics to integrate primary caries prevention into their menu of well-child services and, by so doing, demonstrate to other clinics in the state how easy it is to include primary caries prevention in well-child visits and get reimbursed for the effort. To date, 35 clinics in the state have been trained to add the intervention to well-child care and are in various stages of implementing it.
To Learn More
Online training on how to prevent caries, do a lift-the-lip examination to look for white spots—the earliest sign of caries, and apply a fluoride varnish is available at www.meded.umn.edu/apps/
pediatrics/FluorideVarnish/index.cfm. The University of Minnesota offers one CEU for physicians, other health care providers, and ancillary clinic staff who take the web-based course and critique it.
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Part of Preventive Care
Applying fluoride varnish is a primary prevention strategy, not unlike giving immunizations. As responsible providers of primary medical care to children, pediatricians and family physicians have a responsibility to care for the whole child, including the mouth. The cost of applying varnish is minimal (one dose of fluoride varnish costs approximately $1.50), and it takes only a few minutes for a clinic “point person” to assess a child’s risk for caries (15 to 30 seconds), provide anticipatory guidance to the caregiver, and apply the varnish (less than 5 minutes).
The cost to society of having a child suffer from dental caries is great. Many parents of high-risk children who are suffering from dental pain out of despair end up in emergency rooms, where they receive high-cost ($450 to $500 per visit) but incomplete care, as emergency room physicians only treat pain and infection and do not do restorative procedures that would correct the underlying problem. For the young child who needs several teeth repaired, care can only be provided in an ambulatory surgery setting at a cost of close to $12,000. It also carries a small-but-real risk of death from the anesthesia.
No child should die as two did in 2007 (one from a brain abscess, the other from sepsis) because their abscessed teeth went untreated. That’s why it is up to us, as primary care providers who have a responsibility to protect the entire body, to offer primary caries prevention as part of well-child care in an effort to slow or stop this silent epidemic. MM
Amos Deinard is an associate professor in the department of pediatrics and the School of Public Health at the University of Minnesota. Brenda Johnson is a research associate in the university’s department of pediatrics.
References
1. The Face of a Child: Surgeon General’s Conference on Children and Oral Health, June 12-13, 2000, Washington, DC.
2. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, May 2000. Available at: www.surgeongeneral.gov/library/oralhealth/. Accessed February 17, 2009.
3. Spizak S, Holt K (ed). Building Partnerships to Improve Children’s Access to Medicaid Oral Health Services: National conference proceedings. Arlington,VA: National Center for Education in Maternal and Child Health; 1999.
4. GAO-08-1121 Medicaid: Extent of Dental Disease for Children Has Not Decreased and Millions Are Estimated to Have Untreated Tooth Decay. September 2008. Available at: www.gao.gov/new.items/d081121.pdf. Accessed February 17, 2009.
5. Otto M. For want of a dentist. Washington Post. February 28, 2007:B01.
6. Weintraub JA, Ramos-Gomez F, Jue B, et al. Fluoride varnish efficacy in preventing early childhood caries, J Dent Res. 2006;85(2):172-6.
7. American Dental Association Council on Scientific Affairs. Professionally applied topical fluoride: evidence-based clinical recommendations. J Am Dent Assoc. 2006;137(8):1151-9.
8. Deinard A, Modem, S, Shaw, D. Pediatric Oral Health, Smiles for Tomorrow: An Atlas of Common Dental Pathology for Primary Care Medical Professionals. Twin Cities: Regents of the University of Minnesota. Department of Pediatrics, 2003.