The role of the pediatrician in the oral health of children: A national survey

Objectives. To assess pediatricians' knowledge, attitudes, and professional experience regarding oral health, and to determine willingness to incorpor ate fluoride varnish into their practices. Background. Poor and minority children suffer disproportionately from denta l caries and have limited access to dental care. In a recent analysis of na tional survey data, the General Accounting Office reported that poor childr en had 5 times more untreated decay than did children from higher income fa milies. Untreated decay can lead to problems with eating, speaking, and att ending to learning. Children who are poor suffer 12 times the number of res tricted activity days because of dental problems, compared with more afflue nt children. Despite higher rates of dental decay, poor children had one half the number of dental visits compared with higher income children in 1996. Medicaid's Early Periodic Screening Diagnosis and Treatment (EPSDT) program is intende d to provide regular dental screenings and appropriate treatment but has ap parently played a limited role in improving access to dental care for poor children. According to a report by the Office of the Inspector General of t he Department of Health and Human Services, only 20% of children under 21 y ears of age, who were enrolled in Medicaid and eligible for EPSDT, actually received preventive dental services. By increasing their involvement in oral health prevention during well-child care visits, pediatricians may be able to play an important role in improv ing the dental health of their patients who have difficulty obtaining acces s to professional dental care. However, it is unclear to what degree pediat ricians are knowledgeable about preventive oral health and the extent to wh ich they may already be participating in prevention and assessment. Also, l ittle is known about the incidence of dental problems in pediatric practice , and whether pediatricians perceive barriers to their patients' receiving professional dental care. Finally, it is important to know how pediatrician s value the promotion of oral health and whether they would be willing to t ake on additional activities aimed at its improvement. We addressed these q uestions in a national survey of pediatricians. Design. We surveyed a national sample of 1600 pediatricians randomly select ed from the American Medical Association Master File to assess their knowle dge, current practice, and opinion on their role in the promotion of oral h ealth; experience with dental decay among patients and in referring patient s for professional dental care; and willingness to apply fluoride varnish. Results. Of 1386 eligible survey recipients, 862 returned surveys for a res ponse rate of 62%. Respondents reported seeing dental problems regularly. T wo thirds of respondents observed caries in their school-aged patients at l east once a month. Of the respondents, 55% reported difficulty achieving su ccessful dental referrals for their uninsured patients and 38% reported dif ficulty referring their Medicaid patients. More than 90% of the respondents agreed that they had an important role in identifying dental problems and counseling families on the prevention of caries. Moreover, respondents were interested in increasing their involvement: 74% expressed a willingness to apply fluoride varnish in their practices. One half of the respondents, ho wever, reported no previous training in dental health issues during medical school or residency, and only 9% correctly answered all 4 knowledge questi ons. Conclusion. Access to dental care and unmet dental health needs are serious , underaddressed problems for poor and minority children in the United Stat es. In promoting preventive oral health, pediatricians benefit all children and particularly the underserved. We know of 2 states, Washington and Nort h Carolina, that have acknowledged, through the provision of reimbursement, that pediatricians have a unique opportunity at well-child care visits to provide caries prevention counseling and care to poor children. Based on results of this survey, we believe it bodes well for expanding ped iatrician involvement in oral health into other states. Specifically, we fo und that pediatricians overwhelmingly believe that they have an important r ole and are already involved in providing anticipatory guidance on oral hea lth issues. However, lack of up-to-date information and knowledge as well a s the difficulty pediatricians perceive in referring some patients for prof essional dental care call into question the current level of effectiveness of pediatricians in promoting oral health. We offer several recommendations to begin the dialogue on expanding the role of pediatricians in preventive oral health: 1. Pediatricians will require adequate training in oral health in medical s chool, residency, and in continuing education courses. We recommend adding a module on oral health and dental care to the undergraduate medical school physical examination skills courses and an oral health rotation to pediatr ic residency curriculums. Having dental professionals provide such instruct ion would enhance acquisition of hands-on skills and could encourage future professional collaboration and cross-referrals. 2. Pediatricians will require current information and guidelines on prevent ive dental care. With the exception of Bright Futures: Guidelines for Healt h Supervision of Infants, Children, and Adolescents, very little is availab le to guide pediatricians in the promotion of oral health in their practice s. The American Academy of Pediatrics (AAP) publication, Guidelines for Hea lth Supervision, provides cursory oral health advice limited to fluoride su pplementation and dental referral. The scientific literature aimed at pedia tricians is also limited. A recent Medline search of the 3 commonly read pe diatric journals identified <20 articles with a primary focus on oral healt h published in the last 10 years. 3. Pediatricians must be ensured that all of their patients, Medicaid and u ninsured included, can receive timely preventive and restorative dental car e. Pediatricians can expand their involvement in oral health prevention, bu t they can never replace the care that dental professionals provide. Furthe r dialogue with our dental colleagues and joint advocacy efforts by the AAP and American Academy of Pediatric Dentistry are needed to address the seri ous problem of disparities in access to dental care. 4. Pediatricians will require sufficient resources to successfully assume g reater involvement in oral health-related activities. Time pressures and in adequate staffing will make it difficult for pediatricians to devote the at tention to oral health that all children deserve.