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The recent standard declaring that children should see a dentist by their first birthday has been endorsed by the American Academy of Pediatrics (AAP), the American Dental Association (ADA) and the American Academy of Pediatric Dentists (AAPD)

Now if only there were enough dentists out there to see all those babies and toddlers.

As dental schools and government payers catch up with new priorities in children’s oral health, dentists and pediatricians are coming together to fill in the gap.

The AAP is now working with the Maternal and Child Health Bureau through an Oral Health Initiative grant to educate and empower pediatricians to screen for oral health, give advice on prevention and even apply a protective fluoride varnish to kids’ teeth. Alongside that effort is a push to get state Medicaid offices to pay the pediatricians for their work.

The issue of children’s oral health has been moving to the forefront in recent years. In 2005, the Centers for Disease Control and Prevention documented an increase in cavities (also known as caries) among children ages 2-5 — with poor children and minorities most affected.

In February, the AAPD received a five-year, $10 million contract from the federal Office of Head Start to establish dental homes for 1 million children enrolled in Head Start programs. In the same month, the ADA Foundation announced a three-year, $300,000 grant to the AAP to fund annual “train-the-trainer” health summits during which pediatricians will learn how to conduct oral health risk assessments, and then return to their states to train others.

Martha Ann Keels, DDS, PhD, serves as chair of the 250-member Pediatric Dentistry and Oral Health section within the AAP. She trained at the University of North Carolina at Chapel Hill and practices with Duke Pediatric Dentistry in Durham, N.C.


What’s the focus of your work today?
“Through various targets, we’re trying to solve this problem in preventing early childhood caries. That’s the number-one chronic disease among children in the U.S. — more common than asthma and ADHD — and it costs this country a lot of money to fix teeth when those caries could have been prevented.

“Putting juice and soda in sippy cups, buying bottled water without fluoride — things like this are why tooth decay in children is so rampant. And it’s so preventable. In addition, the number-one thing that predicts whether people will get cavities in their adult teeth is having had cavities in their baby teeth. So if we can stop the cycle early, we may stop it for life.”

What is the role of pediatricians in this effort?
“As we work to get more pediatric dentists, we’re trying to get pediatricians involved in screening these children and serving in a triage role. Ideally, we would like to have all children in a dental home, but we don’t have the manpower at the moment. That’s why our group is working across the country to get Medicaid to reimburse physicians to screen children’s teeth and also put fluoride varnish on the teeth to strengthen them. Two different studies have shown that’s very effective at holding dental caries at bay.”

How does this approach work at the local level?
“Each community’s got to work out its own system based on its resources. In ours, we’ve got it covered; if there’s a child who needs to be seen, we’ve got a home for them.”

She added, “But many counties don’t have a dental school in them and don’t have all the manpower we do here in the Triangle area. Certain pockets of the U.S. are really struggling, because there are not dentists in those areas. Some counties have gotten donors to give money for ‘tooth buses’ to go from urban to rural areas. It’s also about creating a network for getting those participating doctors and dentists together. At the national level, we’re recruiting liaisons for each state chapter and getting people to come up with solutions together about which children can stay in the pediatrician’s care longer and be managed there.”

What challenges do you face?
“Unlike with Medicare, changing Medicaid is a state-by-state battle. For example, South Carolina will pay the pediatricians to put the varnish on, but not to do the screenings. So it’s these crazy battles with different state governments, where you have to go in and explain why this is needed and that other states have funded this over and above the normal physical exam.”

She went on, “We now have more than 20 states in the U.S. where we’ve worked really hard and gotten these state Medicaid programs to work with us. We’re making headway. The first study to come out of North Carolina shows we are seeing a reduction in caries in children by 36 percent by having the physicians get involved. That’s huge — and California is showing the same thing. So two different states and studies are showing a significant reduction. So I think we’re really going to make a huge turn in preventing tooth decay in children. There’s a lot of positive energy right now.”

How are general dentists involved?
“In years past, there was really no one looking at children under age 3. General dentists who graduated before 2007 weren’t trained to do that, so today they would have to go to CME courses. Both the AAPD and my section are offering a lot of courses for general dentists on how to do infant dental care. Handling an infant for some people is very scary and awkward. But for pediatricians, handling infants is not outside their comfort range. They just need to know what to look at for teeth.”

She added, “General dentists also need to get a comfort level in handling these tiny creatures. So the other angle we’re pursuing is to get the ADA to make an infant dental-care training program part of requirements for dental school.”

What’s the next step for this effort?
“You really have to ingrain these habits early, and the most fertile mind to receive this type of information is really a mother when she’s pregnant or just after giving birth. They’re open to listening, and we’re crazy not to take advantage of that. So the next fertile ground for us is the ob/gyn’s office.
While you’re in your childbirth classes, you can learn to take care of your child’s teeth. All of this is a multi-tiered effort, but I think finally the tolerance of seeing children in the U.S. with rotted-out teeth has finally hit the wall. This is not OK, and it’s something that’s so preventable.”



June 2008

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