I greatly appreciated Dr. Michael Glick’s timely editorial regarding the progress made in the fight against dental caries ("A Job Well Done, but Still a Long Way to Go,"
JADA 2005;136:1506–7
). I agree that progress is being made, but as Dr. Glick implied, that progress has been slow and incremental, as it always is with chronic diseases, barring a breakthrough therapy.
I recently attended the Symposium on the Prevention of Oral Disease in Children and Adolescents, presented by the American Academy of Pediatric Dentistry in Chicago. At the symposium, I learned of several concepts relating to caries.
First, there is no magic bullet for preventing or treating this complex infectious disease. Second, once the disease is well-established in the primary teeth, it has high potential for involving the permanent teeth. Third, there is good plaque (protective) and bad plaque (pathologic). And fourth, a combination of therapies and interventions must be initiated early in life in order to control the disease and facilitate the establishment of good plaque and a lifetime of good oral health.
These therapies and interventions include effective oral hygiene practices, proper nutrition and appropriate use of anti-cariogenic, caries-protective and caries therapeutic agents including fluoridated water, fluoride toothpaste, xyli-tol-containing products, fluoride varnishes, dental sealants, and early and accessible screening for caries disease by health care providers. Because the disease affects low-income and non-white families at higher rates and exhibits the "Pareto Principle" of 80 percent of the disease affecting 20 percent of the population,1 it is crucial to assess risk factors for caries in a given patient, and then apply specific targeted interventions and therapies for each individual patient.2
I believe that it is now well-accepted by pediatric dentistry that early childhood caries is a medical disease prior to becoming a dental surgical disease.3 White spot lesions (early demineralization of enamel) often can be treated medically (under the supervision of an attending dentist) with aggressive hygiene, nutritional support and fluoride applications.
Surely a medical infectious disease such as caries can be more effectively and accurately diagnosed by pediatric medical providers than is the current situation.
A new caries prevention and treatment model, which is already in practice in many locales, needs wider adoption. That model involves education of children’s medical providers to better understand the epidemiology and pathophysiology of this infectious disease that affects over 40 percent of children under 6 years of age and up to 70 percent of low-income children.
To start with, pediatricians must identify more effectively high-caries-risk children in early well-child examinations. Four months of age, when most parents start noticing that their baby is drooling more and inquire about teething, is an opportune time for the physician to determine the family history for caries, which often is transmitted from mother to child, and to give advice regarding initiation of an oral hygiene practice, such as simply wiping the baby’s gums.
At subsequent well-child visits, pediatricians must routinely examine babies’ mouths from front to back (not just the oropharynx) and carefully inspect the baby teeth for signs of pathology. The need to brush the baby’s teeth must be emphasized early on as an absolutely necessary daily health maintenance activity. Routine nutritional counseling should incorporate the concept of caries prevention. At the first sign of any dental pathology, or by age 1 year, we need to refer our patients to dental services.4,5
Why is this model not working? The conventional wisdom is that pediatricians are too busy to deal with oral health issues. Most children’s doctors see 30-plus patients per day. Time constraints during well-child visits, which already must include assessment of the child’s growth, neurological development, behavioral assessment, nutrition practices, vaccination status and safety counseling—not to mention a complete physical examination—often push the oral health assessment to the side. In my experience, it takes less than 30 seconds to inspect the teeth with an otoscope light. While doing this, the health professional can talk about and demonstrate how to clean the teeth.
When talking about nutrition, it is quick and easy to point out the disadvantages of nighttime bottle habits, which not only promote caries but also contribute to chronic nocturnal waking behaviors, which most parents can relate to. Pointing out the risk of chronic dental disease may provide an extra incentive for parents to get their child’s diet off to the right start.
I believe that pediatricians, family physicians and pediatric and family nurse practitioners who see young children in their practices each day need to take more responsibility for reducing the prevalence of this chronic epidemic disease of childhood. Unfortunately, most of our dental colleagues are first seeing patients with dental caries in its more advanced forms.
In my view, this is what needs to be done. First, the American Dental Association, the American Academy of Pediatric Dentistry and the American Academy of Pediatrics all need to advocate more effectively for the incorporation of oral health promotion into pediatric medical practices. Dentists are doing all they can—advocating for fluoridation of water supplies, placing sealants and varnishes and educating families about caries prevention. Pediatricians need to step up to the plate.
A model for educating and empowering pediatricians to take a more active role in the prevention of early childhood caries has been successfully implemented in North Carolina6; there is no reason that this cannot be done nationally.
I have incorporated into my practice the "pediatric dental referral." If I am seeing a child with any suspected dental pathology, such as white spots, enamel hypoplasia, enamel staining or frank caries, I generate a formal referral to pediatric (or general) dental services, just as I would make a cardiology referral for a child with a heart murmur. My office can then track and facilitate the setting up of an appointment in a timely way. The dental disease of my patient now has a paper trail.
We should advocate for medical insurers and dental insurers to coordinate care more effectively, and make dental referrals by medical doctors a seamless experience for the patient. One could even argue that if early childhood caries is a medical disease in its earliest manifestations, then medical insurers of children should cover the initial dental assessment.
Pediatric dentists, general dentists, orthodontists and dental hygienists can also push harder to bridge the disciplines of medicine and dentistry. Send educational materials and newsletters about children’s oral health to your pediatricians’ offices. Offer to give a presentation about childhood caries to local pediatric societies. After seeing a patient in the dental office, send a brief consultative report to the child’s pediatrician, whether he or she was referred formally or not. Teach us what to do and encourage us to do a better job.
Pediatricians have an opportunity to become the frontline of defense against early childhood caries, but not without the help and support of the dental profession, which has brought us the knowledge and tools to make a big difference in the outcome of this most common chronic disease of childhood. We must care for America’s children properly and thoroughly as a medical/dental team, working together.
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