Oral health should start in the pediatric office, during well-baby visits

May 2005

ORLANDO – Although a pediatrician may never seem to have enough time in the well-baby and well-child visits, there could be one more thing to consider; a pediatric patient’s dental health.

Paul Casamassimo, DDS, MS, professor, chair and chief of dentistry at Ohio State University and Columbus Children’s Hospital, said that within the confines of the ideal 18-minute well-child visit – although he said he understands the visit is more like 13 minutes, if the pediatrician is lucky — a pediatrician can give parents advice on teething, proper tooth care and in older children, screen for cavities and gum disease from the eruption of the first tooth.

“There’s a lot of work you already do that relates to oral health,” Casamassimo said, including safety, injury prevention, personal hygiene and fluoride treatment. “…A bunch of prevention you’re already doing that you can build upon to incorporate oral health. Start small.”

Casamassimo made his remarks during the American Academy of Pediatrics (AAP) Super CME 2005 meeting held here last month.

Why not oral health?

There are several reasons why oral health has not historically been a significant part of pediatric practice, Casamassimo said, including the increasing number of health topics competing for a slice of the well-child and well-baby visit, such as obesity and routine childhood immunizations.

But a pediatrician knows his or her practice, he said, and an assessment of need could reveal that he or she might be able to make an impact on the dental health practices of patients.

There are four steps to consider in the process of incorporating oral health into a pediatric practice. Know what is expected, determine a practice’s risk, get the tools and apply the best practices, Casamassimo said.

“Your practice may not need oral health,” he said. Some things to consider are whether patients are children on Medicaid; they might not get the same services as those children with insurance, Casamassimo said. Also, he suggested looking for racial disparities related to the income of families in one’s practice.

The AAP’s current policy on dental health for infants and toddlers states that every child should have an oral health risk assessment by the time they are 6 months of age, when teething starts, by a qualified practitioner. Children who are determined “at-risk” should see a dental health professional between ages 6 and 12 months. Up until 10 years ago, a child was not referred to a dentist until age 3, no matter what, Casamassimo said.

The best strategy for the initial oral health service is for the pediatrician to see the child, and educate the patient and family about good oral hygiene.

Some pediatricians, however, might be concerned about dipping into dental health without the dental education background of a dentist, and because “as physicians you have so many things you have to learn and be experts at,” Casamassimo said.

An evidence-based review by Rozier et al in 2003, concluded that pediatricians do not do well in prescribing fluoride, but Casamassimo said that pediatricians can identify a cavity like a dental pro.

“Physicians do about as well as dentists,” Casamassimo said. “We’re pretty much even in identifying a tooth that needs to be treated using the naked eye.”

Screen, clean, wean and fluorine

After one has assessed and determined a need in his or her practice for oral health, Casamassimo suggested a four part plan in caring for oral health; screen, clean, wean and fluorine.

Screening includes looking for dental caries, or cavities, and other risk signs such as plaque on a child’s teeth.

For children younger than age of 3, take a tongue depressor and scrape the front of the child’s front teeth and if plaque is present, that child is at risk, he said. Also look for white, matted areas on a child’s tooth surface, called decalcification, another sign of a beginning cavity.

Cleaning and remineralizing the tooth with fluoride will help prevent the tooth from breaking down.

“If you see open cavities, those merit referral to a dentist,” he said.

Plaque and decalcification are both good reasons to refer the child to a dentist, Casamassimo said.

Also, find out if the child’s mother is in good dental health. If mothers have cavities, they can transmit virulent bacteria to their children.

The next step is to clean, or teach and encourage oral hygiene with the patients’ parents. Adults brush their teeth for healthy gums and fresh breath, Casamassimo said, because there is no correlation between brushing and the prevention of tooth decay. However, brushing could prevent tooth decay in children.

“Getting a parent to clean the kid’s teeth from the minute they’re in [the mouth] is important,” he said. “If you get that plaque off, you might prevent tooth decay.”

Toothpaste is not necessary until the second year of life, he further advised. He said soft brushes are recommended for any age, and that “parents must brush, not kids, until well into elementary school.” Casamassimo said to limit toothpaste use to a pea-size amount in the first three to four years of life.

Eliminating night use and weaning the child off the baby bottle is very important, Casamassimo said. There is a growing body of evidence that feeding habits in the American culture are dramatically changing, and children are on the bottle until 2 1/2 years of age as well as still going to bed at night with it, he said. Sippy cups, he added, only foster a snacking type of habit, as the child is continuously drinking from the cup.

“Another part of weaning is to reduce sugar consumption,” Casamassimo said. “We know from multiple studies that if a kid gets three sugar exposures a day in any form, that puts them over the limit for tooth decay.”

Finally, pediatricians can monitor a child’s fluoride intake. Fluoride prescription can begin at 6 months of life, and is still based on water measurement. Consider a child’s potential source of fluoride intake, from swallowing toothpaste to drinking water.

Pediatric practices can also offer a fluoride varnish, which requires two to four applications a year. Children can resume normal eating habits after the application but it is advised that brushing is delayed a day.

Casamassimo said the varnish is a yellow, “gooey kind of stuff,” and teeth are dried before application. Varnish is something that pediatric practice staff can apply and that it is an “effective way of getting fluoride to high-risk populations.”

Something to chew on

Casamassimo said most oral health concerns could be dealt with in about a minute to a minute and a half. Ask if the child’s teeth are being brushed, talk about weaning and reducing sugar consumption.

Have brochures and handouts ready for parents and build a referral list of pediatric and general dentists nearby.

Bone up on the literature about oral health in pediatric practice, find out about the successes and trials other practices are experiencing or have experienced (for more, see box at right).

Refer a child on to a dentist if they have special health care needs, are at risk for tooth decay, spent a long time on the bottle and/or who have mothers with high dental caries.

In the fourth step of integrating oral health into a practice, Casamassimo said to create awareness in the office. “If your staff is not behind you, you’re in trouble,” he said.

Also, a pediatrician may want to consult with a dentist in training the office staff to integrate oral health.

In addition to practice measures, a pediatrician can become a voice for oral health.

“Advocate for oral health outside of your office,” Casamassimo added. “In your Academy chapters.”

Get into the debate against soda machines in schools, he added, and community water fluoridation.

For more information:

• Casamassimo P. Making oral health work in the 18-minute well-child visit. Presented at the American Academy of Pediatrics Super CME meeting. April 13-16, 2005. Orlando.