PEDIATRICS Vol. 101 No. 1 January 1998, p. e6

ELECTRONIC ARTICLE:
Fluoride Supplement Prescribing and Dental Referral Patterns Among Academic Pediatricians

Michael W. Roberts^*, Martha Ann Keels^§, Michael C. Sharp, and Jasper L. Lewis Jr

From the Departments of ^* Pediatric Dentistry, School of Dentistry, and  Pediatrics, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; ^§ Departments of Surgery and Pediatrics, Duke University Medical Center, Durham, North Carolina; and  DDS, Private Practice.

	ABSTRACT

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Objective.  To determine how well the current fluoride supplementation schedule was known by academic pediatricians and to examine the fluoride supplement prescribing and dental referral practices among primary care faculty pediatricians at four medical centers.

Setting.  Four university medical centers in North Carolina.

Subjects.  Primary care faculty pediatricians.

Method.  A questionnaire pretested for clarity was distributed to all identified full-time primary care pediatric faculty (42 members).

Results.  A total of 40 completed questionnaires were returned. Thirty-seven (93%) primary care faculty pediatricians reported that they routinely addressed the need for fluoride supplements for their patients, but only 28 (70%) determined the fluoride content of the drinking water before prescribing supplements. Thirty-five (87.5%) began supplements at the correct age, but fewer knew the correct doses for children of various ages. Only 23 (58%) referred their patients for oral examination and preventive care before the age of 36 months, contrary to American Academy of Pediatrics recommendations.

Conclusions.  Pediatricians in an academic setting would be expected to be more knowledgeable of current recommendations than those in private practice. Failure to know and teach correct fluoride supplement recommendations and failure to recommend early professional dental involvement can result in less than optimum oral health.

	INTRODUCTION

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Pediatricians and family physicians have the opportunity to affect the oral health of children because of their early and frequent contact during well-child and chronic condition visits.^1,2 Children <5 years of age see a physician more often than they do a dentist.³ Two effective ways of preventing caries in children are ensuring that they receive the recommended amount of dietary fluoride and that they are under the care of a dentist.^4,5

Fluoride can increase the resistance to caries, but too much fluoride can result in dental fluorosis.^6,7 The goal is to achieve a level of fluoride exposure that maximizes the benefits while minimizing the risk. Dietary fluoride supplementation is recommended for children living in areas with less than optimum fluoride in the drinking water supply.^8,9

The current dietary fluoride supplement schedule was adopted by the Council on Dental Therapeutics of the American Dental Association in April 1994¹⁰ and is presented in Table 1. Subsequently, this new guideline was accepted by the American Academy of Pediatric Dentistry (AAPD) the same year¹¹ and the American Academy of Pediatrics (AAP) in 1995.¹² The new supplement schedule represented a significant change from previous recommendations. The age of the child and the amount of fluoride recommended were adjusted to be more conservative. Shulman and coworkers¹³ have suggested that body weight rather than chronological age defines the average dose needed by growing children, but this means of determining the appropriate fluoride dose for an individual child has yet to be adopted.

The perception that many physicians continue to prescribe fluoride supplements inappropriately is a concern among many health care professionals.¹⁴ The present study was designed to determine 1) how well the current fluoride supplementation schedule has penetrated the academic pediatric community; 2) what the fluoride prescribing practices are among primary care pediatricians; and 3) what the dental referral practices are among primary care pediatricians at four university medical centers in North Carolina.

	METHODS AND MATERIALS

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Support for this study was obtained from the chairs/division chiefs of the Departments of Pediatrics at East Carolina University, Duke University, Bowman-Gray (Wake Forest), and the University of North Carolina. The names of the primary care faculty providers were obtained from the departments. Table 2 presents the questionnaire that was pretested for clarity and distributed to all full-time primary care pediatric faculty members identified at the four university medical centers between August 1996 and November 1996. A follow-up request was made to all pediatricians who did not respond to the initial mailing. Each survey participant was given a self-addressed envelope for return of the completed questionnaire.

	RESULTS

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Completed questionnaires were received from 40 of the 42 primary care pediatricians identified, a response rate of 95%. Seven of the physicians reported that they saw patients <12 hours per week; eight reported 12 to 20 hours of clinical activity per week; 13 attended clinic 21 to 30 hours per week, eight reported 31 to 40 hours of patient contact/week, and 4 reported 41 hours per week.

Thirty-seven respondents (93%) stated that they addressed routinely the need for fluoride supplements for their patients. Only 28 physicians (70%) determined the fluoride content of their patients' drinking water before prescribing supplements. However, 6 of the 12 who prescribed supplements without knowledge of the fluoride content of the drinking water recommended that the fluoride content of the water supply be determined as soon as possible through various local and state public health agencies or by referring to information provided by a state agency.

The pediatricians were asked when dietary fluoride supplements should begin. Five (12.5%) stated incorrectly that fluoride supplements should begin at birth. The remaining 35 (87.5%) answered correctly that fluoride supplementation should begin at 6 months of age or on eruption of the first primary tooth. A summary of their responses is presented in Table 3.

The respondents were also asked to identify the correct dietary fluoride supplements to children who consumed nonfluoridated drinking water in their homes. Thirty-six participants (90%) responded correctly that 0.25 mg of fluoride per day is the recommended dosage for a child <3 years of age, 19 (48%) recognized that 0.5 mg of fluoride per day from 3 to 6 years of age was correct, and 22 (56%) correctly identified that 1.0 mg of fluoride per day was appropriate for children from 6 to 16 years of age. Eleven (28%) of the pediatricians identified higher levels of dietary fluoride supplements for a given age group than are recommended.

Table 4 summarizes the pediatricians' reported recommendations relative to their patients being seen first by a dentist for an oral examination. None recommended that a child be seen before their first birthday. Twenty-three (58%) referred their patients to a dentist between the ages of 13 and 35 months of age for their first oral examination, and 17 (43%) reported delaying referral to a dentist until their patients were 36 months of age.

	DISCUSSION

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The survey instrument used in the present study was completed at leisure by the respondents. A possibility exists that some participants sought out the correct answer to a question before completing the questionnaire. To the extent that this bias exists, the number of correct responses would be overstated. This would suggest that the data report a best-case scenario.

It was encouraging to discover that 93% of the responding primary care pediatricians reported addressing routinely the fluoride needs for their patients. However, it was disturbing to note that many reported prescribing fluoride supplements without first determining the level of fluoride content in the home drinking water and that 12.5% of the physicians believed that fluoride supplementation should begin at birth. This finding could exacerbate the increase in the prevalence of fluorosis reported recently.^7,15

The current recommendation that children <3 years of age receive 0.25 mg of fluoride per day was recognized by most respondents, but less than half identified correctly that the correct dose for children 3 to 6 years of age was 0.5 mg per day, and only slightly more than half acknowledged that the correct daily amount of fluoride for children 6 to 16 years of age was 1.0 mg of fluoride per day. These findings suggest that a number of pediatricians were still following pre-1994 guidelines. The most recent recommendations have not optimally penetrated the academic primary care pediatric community. This is consistent with similar studies before 1994.^20,21 It would be expected that pediatricians in an academic setting would be more up to date than those in private practice. So if, these knowledge gaps exist in academics, then the voids are likely to be larger among practitioners. There is a need for public health and dental authorities to increase the awareness of all primary care physicians concerning the correct supplement recommendations to optimize the benefits of fluoride to the growing child.^22,23

The AAP and AAPD differ in their recommendations about the age at which a typical child should have its first oral examination by a dentist.^24,25 None of the respondents reported referring their patients to a dentist before the first birthday, as recommended by the AAPD. It is obvious that the primary care pediatricians participating in this survey do not embrace the AAPD's oral health policy on this issue. However, it is of greater concern that <60% of the pediatricians surveyed follow the AAP's recommendation regarding the referral of children by 3 years of age to a dentist for an oral examination. This failure negates the opportunity for dentists to initiate early preventive measures for the child and has often led to the misuse of the nursing bottle, resulting in bottle/nursing caries, and failure to initiate appropriate age-related oral hygiene practices.

	CONCLUSION

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The appropriate use of fluoride supplements is a public health issue. Professional organizations and state health agencies need to be aggressive in the dissemination of the appropriate water testing guidelines and dietary fluoride supplementation recommendations.

Primary care pediatricians on medical school faculties at university medical centers can have significant impact on medical students and pediatric residents. Failure to know and teach the correct fluoride supplement recommendations and failure to encourage early professional dental involvement can result in less than optimum oral health for the child patient. Physicians should be encouraged to refer their patients to a dentist at an early age for well-child and preventive care.

	FOOTNOTES

Received for publication Mar 3, 1997; accepted Aug 11, 1997.

Reprint requests to (M.W.R.) Department of Pediatric Dentistry, School of Dentistry, CB# 7450, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7450.

	ACKNOWLEDGMENT

This study was supported in part by Project MCJ-379494 from the Maternal and Child Health Bureau, Health Resources and Services Administration, Department of Health and Human Services.

	ABBREVIATIONS

AAPD, American Academy of Pediatric Dentistry. AAP, American Academy of Pediatrics.

	REFERENCES

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