Primary care clinicians the missing link in oral health disparities

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LAS VEGAS – Dental health is the most common unmet health need and can severely affect systemic health, according to a speaker at the American Academy of Physician Assistants' 39th Annual PA Meeting.  Disparities in oral health and access to care exist in all ages, but especially in the young, elderly, and uninsured.

“Much oral disease is preventable, or at least controllable,” Wanda C. Gonsalves, MD, an associate professor and medical director of the physician assistant program at the Medical University of South Carolina, told audiences here.

A proponent of Smiles for Life, a comprehensive national curriculum developed by the Society of Teachers of Family Medicine Group on Oral Health, Gonsalves explained some of the key issues and the role that primary care pediatric clinicians play in maintaining children's oral health.

Early childhood caries (ECCs) is an infectious and chronic disease that affects children from when the first tooth erupts to age 5 years. ECC breaks down tooth enamel, typically involving the upper front teeth first. ECC first appears as areas of demineralization that start at the gum line, which is where plaque is most likely located.

ECC is a public-health crisis, according to Gonsalves. Although actual disease prevalence is relatively low, affecting about 5% U.S. children, it disproportionately affects those that are low income, with a prevalence rate ranging from 30% to 50% in this population. To put it in perspective, 80% of decay occurs in 20% of the nation's children.

ECC is the most common chronic childhood disease and is five times more common than asthma and seven times more common than hay fever.

Conducting oral exams

Through regular well-child visits, primary-care clinicians typically see children eight times more often than the dentist does. “You have a real opportunity to make a difference in these children,” Gonsalves said.

Understanding  the sequence in which teeth begin to appear in children is the first step to recognizing ECC, according to Gonsalves. Incisors first start to appear from about six to 12 months of age, followed by the molars at 1 year. A child should have all teeth by the age 3 years.  

The “knee-to-knee” exam is perfect for clinicians who conduct regular exams with infants and toddlers. Ask the child to straddle the parent's lap and lie back on the examiner. Instructing the parent to hug the child before beginning can be helpful for relaxing anxious children, Gonzalves advised.

As for equipment, the clinician will need a good light source, gloves and a tongue depressor. Gauzed is recommended to wipe off plaque that might be on the child's teeth and enable a clearer view of the actual teeth. A mouth mirror will allow a better look at the lingual surfaces.

During observation and palpation, go from outside to inside and from soft tissue to hard tissue. On the face and neck, look for any asymmetry or adenopathy. When looking at the teeth and gum, lift the lower lip down and look for pits and caries.

“If you see pits and wonder whether they are caries or not, don't worry about it,” Gonsalves said. “Any caries will need to be referred to a dentist.”

 A mirror will help visualize the back part of the lingual surface of the teeth. Be sure to inspect the tongue and palate for any abnormalities.

Risk assessment

A risk-factor assessment will dictate how the child should be treated. The three levels of risk are low, moderate, and high.

The lowest risk group consists of people who have dental insurance and/or caregivers and who do not have caries. Low socioeconomic status or a family member with caries will raise risk to moderate. Plaque on the teeth, demineralized white spots, or lack of fluoridated water denote high risk.

Brushing technique

Children should brush teeth twice a day with a pea-sized amount of toothpaste giving equal care to all teeth, with caregivers brushing the child's teeth through the age of 6 years.

Advise caregivers to stand or sit behind the child while brushing. Make sure the lips are lifted back to allow access to the top surface of the teeth. Use a circular motion around the top, back and on the crowns of the teeth. It is important that children not rinse after brushing, as his increases the intake of topical fluoride.

Diet and feeding advice for caregivers

Clinicians should advise care givers to avoid bottles at bedtime and during naps during the first 12 months of a child's life and the use sweetened pacifiers. Caregivers can introduce use of a cup at six months, and try to wean the child from the bottle by age 1 year. Advise against ad lib use of the sippy cup, according to Gonzalves.

For caregivers of children between ages 1 and 5 years, offer the following tips:

  • Discontinued bottle use
  • Limit juice to 4 oz portions and with meals ony
  • Avoid carbonated beverages, which increase acid formation
  • Choose fresh fruits and vegetables and sugar-free grains and snacks
  • Give only milk and water between meals
  • Limit eating occasions to three meals a day, with one snack in between
  • Reserve soda and candy for special occasions

Recommendations state that the dental home be established in the first year of a child's life. If the patient has limited access to dental care, the primary-care clinician has to take a more active role in prevention. “You can play a major role in preventing ECC by initiating early treatment,” Gonsalves said.

Gonzalves WC. “Oral health in pediatric primary care.” Presented at: American Academy of Physician Assistants' 39th Annual PA Meeting. 2011; Las Vegas, Nevada.
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