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One of the largest unmet health needs in the United States is dental care for children. Dental caries is the most common chronic disease of childhood.1 Approximately 60% of U.S. children experience caries in their primary teeth by age 5, and by age 17, 78% of children have caries.2
Various barriers are preventing nearly 12 million U.S. children from receiving dental care.3 Children from poor families face disproportionately high barriers to getting care.1 Eighty percent of dental disease in children is concentrated in 25% of children.1,3
Disparities in Access
Although the overall oral health of the nation has improved dramatically in the last 50 years, a segment of society has been left behind. Minorities, immigrants, people with low incomes, people with special healthcare needs and people in rural areas have the greatest difficulty accessing care and maintaining good oral health.2
Needs are particularly high among poor children: 20.7% of poor white children, 47.2% of poor Mexican-American children and 43.6% of non-Hispanic black children have untreated dental caries.4 Among preschool children who are poor, nearly 30% have untreated cavities, compared to only 6% among children from families at 300% of the federal poverty level.5
A recent federal survey of parents found that 53% of Latino children, 39% of black children and 23% of white children have only good, fair or poor oral health.6
As much as 90% of all caries in school-aged children occurs in pits and fissures. Untreated dental caries, periodontal diseases and other oral conditions can lead to pain, infection and loss of function. These undesirable outcomes can adversely affect learning, communication, nutrition and other activities necessary for normal growth and development.3
 Integral to General Health
Oral health is integral to general health. Oral problems can interfere with eating and adequate nutritional intake, speaking, self-esteem and daily activities. Children with early childhood caries may be underweight because of the associated pain while eating. Nutritional deficiencies in turn can affect childhood cognitive development. The American Academy of Pediatric Dentistry states that dental care is medically necessary to prevent and eliminate orofacial disease, infection and pain, to restore the form and function of the dentition, and to correct facial disfiguration or dysfunction.7 Unrecognized oral disease and postponed care result in exacerbated problems, which lead to more extensive and costly treatment needs.
Young children have the highest rates of tooth decay and dental pain but the lowest rate of oral health care visits.6 All healthcare providers can identify inexpensive ways to help families prevent tooth decay. The primary way is to brush teeth with fluoride toothpaste twice daily. This is the most effective action to ensure plaque removal. Additionally, flossing helps eliminate plaque on teeth and gums. Children who are at risk of dental decay can reduce cavity risk through frequent exposure to small amounts of fluoride; this is best obtained by drinking fluoridated water daily.8 Fluoride supplements may be necessary for children who are at high risk for decay and who live in communities with a low fluoride concentration in drinking water.8
Insurance Reimbursement
Poor access to pediatric dental care is not exclusively a rural problem. An Illinois study found that the limited supply of dentists who accept Medicaid leads to barriers for children in urban centers like Chicago.9 Medicaid is the principal insurer for poor children, and its low reimbursement rate discourages the participation of dentists.10 In 2007, only 1 in 3 children enrolled in Medicaid received any dental services.11
Parent Strategies
Easy, inexpensive and effective strategies exist to improve the dental health of children. Parents should exclude as much sugar as possible from a child's diet because sugar helps attach plaque to the teeth. If a child does indulge in sugary foods, he or she should rinse the mouth afterward.
A child's diet should include food that requires a good amount of chewing, since this generates cleansing saliva. Ample amounts of calcium, proteins and vitamins B and C help children regain calcium lost due to plaque.12 Fruits, vegetables and dairy products provide teeth with all the vitamins necessary for protection.13 Primary healthcare providers can introduce families to these useful nutritional and dental practices.14
Improving Care
When young children have not received adequate preventive care and subsequently develop early childhood caries, therapeutic intervention is necessary. In recent years, some states have enlisted physicians NPs and PAs to deliver oral health services to children, sometimes with reimbursement by Medicaid. These services include dental screenings, fluoride prescription, caries prevention counseling, assessment and referral for dental problems, and even the provision of a caries control treatment (e.g., application of fluoride varnish).15 Using pediatric providers makes sense since they see infants, young children and their caregivers frequently during the first 2 years of life for well-child care and immunizations.3 Most families don't take young children to the dentist until they are 3 years or older.3
An individualized preventive plan based on the Caries Risk Assessment Tool (CAT) is a key component of caries prevention (http://www.orthodontics.org/Caries-RiskAssesmentTool(CAT).pdf).5 The CAT, developed by the American Academy of Pediatric Dentistry, assesses the level of risk for caries development based on clinical, environmental and general health factors. It can be used by both dental and non-dental personnel.
Any risk assessment tool may fail to identify all infants at risk for early childhood caries. Early establishment of the dental home is the ideal approach for disease prevention. Early diagnosis and timely intervention, including appropriate referrals, can prevent the need for more extensive and expensive care after problems develop.14
Common Oral Problems
Common oral health problems seen in primary care practice include dental caries, primary herpetic gingivostomatitis, fibromas, papillomas, candidiasis and congenital epulis.
The first clinically detectable stage of a cavity (caries) is the incipient lesion, which is characterized by an opaque, white appearance. Although a certain amount of mineral loss has occurred by the time this appears, the loss is predominately in the subsurface of the enamel, with the surface of the enamel essentially intact and amenable to demineralization. The caries can spread and lead to abscess formation or cellulitis. Referral to a dentist is needed. If pain is present, pain medication and antibiotics are needed.16
Primary herpetic gingivostomatitis is an infection of the oral and perioral tissues. It is associated with elevated temperature, dehydration, discomfort, malaise, enlargement of the lymph nodes and intense red gingival vesicles that rupture.17 The vesicles are located throughout the mouth. The infection results in ulcers, drooling and halitosis. Treatment involves supportive therapy, hydration and antipyretics. The infection usually resolves in 7 to 10 days.
Fibromas and papillomas of the oral cavity result from reactive connective tissue hyperplasia caused by a chronic irritant.18 Most fibromas are less than 1 centimeter in diameter. They are pale pink, smooth and firm, and they have a sessile or pedunculated base. Fibromas may occur on any area of the oral mucosa but are most often located on the palate, tongue, cheek or lip. The papilloma has a soft, cauliflower-like surface. It is pink to white in color, and it is generally a solitary lesion. It can be located anywhere in the mouth. Treatment involves surgical excision and removal of the source of the irritation.19
Candidiasis, a fungal infection that may be present in infancy, appears as a soft white plaque coating the mucosa and palate. When the coating is removed with a gauze pad or tongue blade, the undersurface is red and raw. Candidiasis should be treated with an antifungal medication such as Nystatin oral suspension.
Congenital epulis is a localized pedunculated or sessile smooth-surfaced lesion that is pink to red in color. It may be present at birth, and it is usually located in the upper anterior jaw. It may cause feeding problems and, depending on its size and the degree to which it interferes with feeding, it may require surgical removal.17
Conclusion
Where dental provider shortages exist, using existing healthcare providers can help strengthen the oral health safety net. When oral health assessments are conducted as part of a comprehensive healthcare examination, NPs and PAs can play a pivotal role in reinforcing self-care practices. Prevention of oral disease requires persistent daily care. Good oral health is strongly related to personal health beliefs and behaviors. Basic oral health services in connection with community-based primary care services may ensure holistic, comprehensive health care. Improving access to oral healthcare and reducing disparities in oral health requires both institutional and health policy changes.2
Stacie Zais is family nurse practitioner at Marshfield Clinic in Eau Claire, Wis.
References
1. Dye BA, et al. Trends in oral health status: United States, 1988-1994 and 1999-2004. Vital Health Stat. 2007;11(248):1-92.
2. Office of the surgeon general. National call to action to promote oral health. Rockville, MD: National Institute of Dental and Craniofacial Research; 2003. NIH Publication No. 03-5303.
3. Lewis CW, et al. Preventive dental care for children in the United States: a national perspective. Pediatrics. 2007;119(3);544-553.
4. Acs G, et al. Effect of nursing caries on body weight in a pediatric population. Pediatr Dent. 1992;14(5):302-305.
5. American Academy of Pediatric Dentistry Council on Clinical Affairs. Policy on use of a caries-risk assessment tool (CAT) for infants, children, and adolescents. Pediatr Dent. 2008-2009;30(7 Suppl):29-33.
6. Centers for Disease Control and Prevention. Untreated Dental Caries (Cavities) in Children Ages 2-19, United States. http://www.cdc.gov/Features/dsUntreatedCavitiesKids/. Accessed May 17, 2011.
7. American Academy of Pediatric Dentistry. Definition of medically necessary care. Pediatr Dent. 2007;29:14.
8. American Dental Hygienists' Association. CDC Releases guidelines on fluoride use to prevent tooth decay. http://www.adha.org/profissues/cdc_fluoride_guidelines.htm. Accessed May 17, 2011.
9. Elliott VS. Tooth or consequences: the costs of poor dental fitness. Am Med News. March 3, 2008. http://www.ama-assn.org/amednews/2008/03/03/hlsa0303.htm. Accessed May 17, 2011.
10. Huff M, et al. Self-esteem: a hidden concern in oral health. J Commun Health Nurs. 2006;23(4):245-255.
11. Adequacy of Dental Programs for Medicaid-Eligible Children. http://www.aap.org/ORALHEALTH/cohas/pdf/13_Slides-Overcoming-Barriers.pdf. Accessed May 24, 2011.
12. Holtzman J. Simple, effective - and inexpensive - strategies to reduce tooth decay in children. Infant, Child, & Adolescent Nutrition. 2009;1(4):225-231.
13. Prevent and stop tooth decay. Dental Health Magazine. July 8, 2009. http://worldental.org/teeth/prevent-and-stop-tooth-decay/832/. Accessed May 17, 2011.
14. Lee JY, et al. Examining the cost-effectiveness of early dental visits. Pediatr Dent. 2006;28(2):102-105,192-198.
15. American Academy of Pediatrics. A guide to children's dental health. [Brochure]. Elk Grove Village, Ill.: AAP; 2007.
16. Weinstein P, Milgrom P. Early Childhood Caries: A Team Approach to Prevention and Treatment. Seattle, WA: University of Washington; 1999.
17. Delaney JE, Keels MA. Pediatric oral pathology: soft tissue and periodontal conditions. Pediatr Clin North Am. 2000;47(5):1125-1147.
18. American Academy of Pediatric Dentistry Clinical Affairs Committee. Guideline on behavior guidance for the pediatric dental patient. Pediatr Dent. 2007;29:115-124.
19. Gehshan S, Wyatt M. Improving oral health care for young children. National Academy for State Health Policy. Published 2007. http://www.nashp.org/sites/default/files/improving_oral_health.pdf. Accessed May 17, 2011.
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