Dental Caries: A Silent Epidemic
By Amos Deinard, MD, MPH

“The Mouth is Part of the Body.” With these words, repeated frequently over three days, did the Surgeon General’s 2000 Conference on Oral Health in America open.  For those of us who are primary care practitioners, the mouth should be as much a focus of our attention as the other organs even though, for some children (primarily those who come from families with dental insurance or the ability to pay for care out-of-pocket), dentists, too, are involved in the care of their teeth.

Dental caries (the process, not the hole (cavity)) today has achieved “silent epidemic” proportions;  its magnitude and reasons for it are described in a recent report by the GAO: Medicaid - Extent of Dental Disease in Children that describes how the epidemic continues to involve more children annually, with millions estimated to have untreated tooth decay (September 2008). 

Caries is an infectious disease, caused by bacteria that are transferred primarily from the caregiver’s mouth to the child’s mouth (wetting pacifier with saliva before insertion; pre-chewing or pre-tasting food).  The bacteria in plaque metabolize sugars in food and drink, creating acidic excrement which etches enamel and initiates the caries process. 

Caries is the most common chronic disease of childhood, five times more common than asthma and seven times more common than hay fever.  If care of asthmatic children can be on everyone’s short list of important conditions to address, similar attention should be paid to a condition that is five times more common.

Today, 80% of caries burden is found in 30% of children, (Medicaid/CHIP enrollees and those from working-poor, uninsured families), despite the fact that many of those children who have caries live in communities with fluoridated public water (though Minnesota is 98.6% fluoridated, the water table is generally fluoride-poor).  This observation underscores the importance of access to a dental home (i.e., a clinic that will see a child whenever and for whatever reason). 

Nationwide, private practice dentists generally are unwilling to care for Medicaid/CHIP-eligible children or to offer care on a sliding-fee schedule to the uninsured.  To make matters worse, general dentists who see the majority of children in greater Minnesota have had little experience with one and two year-olds while in training and are thus uncomfortable caring for them, regardless of risk status, and so advise caregivers to begin dental care at age three or four despite the policies of AAP and AAPD that every child should have a dental home by age one. 

Some may argue that since primary teeth are ultimately shed, there is no need to worry about them.  In reality, their retention is important for the correct eruption of permanent teeth.  In addition, a child who has chronic pain from oral pathology of primary teeth does not eat well or, attend well and may fail to thrive.  Abnormal dentition may also affect development of speech and has a deleterious effect on self-esteem. 

Those of us who are primary care providers can address this silent epidemic by introducing primary caries prevention intervention (PCPI) into the C&TC examination (or as part of an episodic visit).  PCPI has five components: gross oral examination with referral of any child with apparent pathology, assessment of risk, caregiver education about caries etiology and the caregiver’s role in prevention, quarterly application of fluoride varnish to the teeth of high-risk children according to recommendations of the ADA, and advising the caregiver of the importance of a dental home by age one.

Risk assessment (15 seconds, paper-and-pencil), anticipatory guidance (1-2 minutes) and fluoride varnish application (less than 5 minutes) should be delegated to a CMA or LPN, while a gross oral examination and promotion of the dental home should be done by the primary care provider (MD, NP, PA).  DHS and the Health Plans will reimburse a fee for the C & TC examination and, in addition, a fee for the application of fluoride varnish (must bill D-1206 along with the C & TC visit code to get reimbursed for the varnish application).  PCPI is an instance of primary prevention which is, at its most basic level, the cornerstone of primary pediatric care (think immunizations), whether provided by pediatric or family medicine providers.

Despite availability of training and reimbursement, primary care medical providers have been slow to incorporate PCPI into the C&TC examination while still urging every parent to find a dental home for her/his child by age one.  Providers should advise the caregiver to call the child’s healthplan or Delta Dental (Doral for those enrolled with UCare) for a list of safety-net dentists. 

Actions to improve oral health in Minnesota should occur before we have our own Deamonte Driver (the 12 year old Maryland boy who, in 2007, died of a brain abscess secondary to an abscessed tooth which his mother could not get treated).  Until dentists return to the pre-1995 era when they saw all children, PCPI is the best way to ensure healthy mouths of high-risk children. 

For assistance in initiating PCPI in your practice, contact Amos Deinard, MD, MPH, who has funding from the National Children’s Oral Health Foundation for this purpose.