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PEDIATRICS Vol. 106 No. 6 December 2000, p. e84
,,
, ¶
From the * Child Health Institute; University of Washington;
Division of General Pediatrics, University of Washington;
§ Department of Pediatric Dentistry, School of Dentistry, University of
Washington; Department of Medicine, University of Washington; and
the ¶ Center for Cost and Outcomes Research, University of Washington,
Seattle, Washington.
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ABSTRACT |
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Top
Abstract
Methods
Results
Discussion
Conclusion
References
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Objectives. To assess pediatricians' knowledge, attitudes, and professional experience regarding oral health, and to determine willingness to incorporate fluoride varnish into their practices.
Background. Poor and minority children suffer disproportionately from dental caries and have limited access to dental care. In a recent analysis of national survey data, the General Accounting Office reported that poor children had 5 times more untreated decay than did children from higher income families. Untreated decay can lead to problems with eating, speaking, and attending to learning. Children who are poor suffer 12 times the number of restricted activity days because of dental problems, compared with more affluent children.Despite higher rates of dental decay, poor children had one half the number of dental visits compared with higher income children in 1996. Medicaid's Early Periodic Screening Diagnosis and Treatment (EPSDT) program is intended to provide regular dental screenings and appropriate treatment but has apparently played a limited role in improving access to dental care for poor children. According to a report by the Office of the Inspector General of the Department of Health and Human Services, only 20% of children under 21 years of age, who were enrolled in Medicaid and eligible for EPSDT, actually received preventive dental services. By increasing their involvement in oral health prevention during well-child care visits, pediatricians may be able to play an important role in improving the dental health of their patients who have difficulty obtaining access to professional dental care. However, it is unclear to what degree pediatricians are knowledgeable about preventive oral health and the extent to which they may already be participating in prevention and assessment. Also, little is known about the incidence of dental problems in pediatric practice, and whether pediatricians perceive barriers to their patients' receiving professional dental care. Finally, it is important to know how pediatricians value the promotion of oral health and whether they would be willing to take on additional activities aimed at its improvement. We addressed these questions in a national survey of pediatricians.
Design. We surveyed a national sample of 1600 pediatricians randomly selected from the American Medical Association Master File to assess their knowledge, current practice, and opinion on their role in the promotion of oral health; experience with dental decay among patients and in referring patients for professional dental care; and willingness to apply fluoride varnish.
Results. Of 1386 eligible survey recipients, 862 returned surveys for a response rate of 62%. Respondents reported seeing dental problems regularly. Two thirds of respondents observed caries in their school-aged patients at least once a month. Of the respondents, 55% reported difficulty achieving successful dental referrals for their uninsured patients and 38% reported difficulty referring their Medicaid patients. More than 90% of the respondents agreed that they had an important role in identifying dental problems and counseling families on the prevention of caries. Moreover, respondents were interested in increasing their involvement: 74% expressed a willingness to apply fluoride varnish in their practices. One half of the respondents, however, reported no previous training in dental health issues during medical school or residency, and only 9% correctly answered all 4 knowledge questions.
Conclusion. Access to dental care and unmet dental health needs are serious, underaddressed problems for poor and minority children in the United States. In promoting preventive oral health, pediatricians benefit all children and particularly the underserved. We know of 2 states, Washington and North Carolina, that have acknowledged, through the provision of reimbursement, that pediatricians have a unique opportunity at well-child care visits to provide caries prevention counseling and care to poor children. Based on results of this survey, we believe it bodes well for expanding pediatrician involvement in oral health into other states. Specifically, we found that pediatricians overwhelmingly believe that they have an important role and are already involved in providing anticipatory guidance on oral health issues. However, lack of up-to-date information and knowledge as well as the difficulty pediatricians perceive in referring some patients for professional dental care call into question the current level of effectiveness of pediatricians in promoting oral health. We offer several recommendations to begin the dialogue on expanding the role of pediatricians in preventive oral health:
Dental caries comprise the single most common chronic
disease affecting children in the United States today.1
Although the incidence of caries has decreased markedly in the last 50 years, primarily attributable to increasing exposure to fluoride,
dental decay remains a serious problem, especially among individuals of
low-income and minority status. A report from the National Institute of
Dental and Craniofacial Research2 indicates that 80% of
caries occur in only 25% of children. Latino, American Indian, and
Alaska Natives are at especially high risk for developing early
childhood caries, sometimes called "baby bottle tooth decay." In
some Native American communities, 60% to 80% of children are
affected.3
Limited knowledge about oral hygiene and difficulty accessing
preventive dental care are believed to contribute to the racial and
income disparity in the frequency of caries. Poor and minority children
are more likely to have untreated dental caries, compared with more
affluent white children.4 For example, in a recent
analysis of national survey data, the General Accounting Office
reported that poor children had 5 times more untreated decay than did
children from higher income families.5 Untreated
decay can lead to problems with eating, speaking, and attending to learning. Children who are poor suffer 12 times the number
of restricted activity days caused by dental problems, compared with
more affluent children.5
Despite higher rates of dental decay, poor children had one half the
number of dental visits, compared with higher income children in
1996.5 Medicaid's Early Periodic Screening Diagnosis and
Treatment (EPSDT) program is intended to provide regular dental
screenings and appropriate treatment but has apparently played a
limited role in improving access to dental care for poor children.
According to a report by the Office of the Inspector General of the
Department of Health and Human Services,6 only 20% of
children under 21 years of age, who were enrolled in Medicaid and
eligible for EPSDT, actually received preventive dental services.
By increasing their involvement in oral health prevention during
well-child care visits, pediatricians may be able to play an important
role in improving the dental health of their patients who have
difficulty obtaining access to professional dental care. This approach
would offer many advantages over the current model, in which most
children do not visit a dentist until after 3 years of age and many
poor children are unable to access dental care at all. Regular
preventive visits to a pediatrician or other primary care provider,
which begin early in infancy and occur on a regular, well-accepted
schedule, would allow for early assessment of a child's oral health.
In addition, pediatricians and other primary care providers already
have an established role in the prevention and early identification of
health problems and routinely discuss age-appropriate anticipatory
guidance on a variety of topics. This role potentially could be
expanded to include counseling on caries prevention, assessment and
referral for dental problems, and even provision of a caries control
treatment, such as application of fluoride varnish. Fluoride varnish is
easily and quickly applied to children's teeth. When used at least
twice a year, fluoride varnish has been shown to lead to a 38%
reduction in dental decay according to a meta-analysis on the
topic.7 Since 1998, Washington state Medicaid has
reimbursed physicians and nurse practitioners $18.18 per visit to apply
fluoride varnish 3 times a year to children under 19 years of age.
North Carolina Medicaid is currently pilot testing a program to
reimburse physicians to provide oral health anticipatory guidance and
fluoride varnish to children <3 years of age.
Several sources on health supervision for children advise pediatricians
and other primary care providers to counsel families on basic oral
hygiene.8,9 However, it is unclear to what degree
pediatricians are knowledgeable about preventive oral health and to
what extent they may already be participating in prevention and
assessment. Also, little is known about the incidence of dental
problems in pediatric practice and whether pediatricians perceive
barriers to their patients' receiving professional dental care.
Finally, it is important to know how pediatricians value the promotion
of oral health and whether they would be willing to take on additional
activities aimed at its improvement. We addressed these questions in a
national survey of pediatricians.
Using the American Medical Association (AMA) Master File, we
recruited a national sample of pediatricians. This list is not limited
to members of the AMA and is considered to be the most inclusive source
of information on licensed physicians in the United States. The AMA
Master File authorized vendor, NDC Health Information Services
(Phoenix, AZ), provided us with a randomly selected list of 1600 general pediatricians between the ages of 25 and 65 years, based in
hospital or clinic practices. This age range was specified to ensure
that the majority of recipients were established in full-time practice.
The database provided names and addresses, information on board
certification, and year of graduation from medical school.
Participants received a 3-page questionnaire and a prepaid return
envelope. A letter from the American Academy of Pediatrics (AAP)
endorsing this study was also included. Subjects were instructed to
return a blank survey if they were no longer in practice or if they did
not include well-child care within their scope of practice. After the
first mailing to the entire sample, up to 3 subsequent
mailings were made to those who had not responded to the previous
mailings using procedures recommended by Salant and
Dillman.10 The institutional review board of the
University of Washington approved all study activities.
Survey Instrument
Demographic information collected from the respondents included
number of years in practice, number of hours of previous oral health
training, number of patients seen per week, number of hours per week
providing patient care, and practice type. Information on practice
location (urban, suburban, and rural), reimbursement type, and
approximate racial/ethnic distribution of respondents' patient
populations was also obtained.
The survey questions were divided into 4 domains. These domains were
chosen based on review of the literature and important themes that
emerged during pilot testing of an earlier version of the survey
instrument.
METHODS
Top
Abstract
Methods
Results
Discussion
Conclusion
References
Statistical Analysis
Descriptive statistics were generated on demographic variables.
2 analysis was used for comparing categorical
variables and Student's t test was used to compare means of
continuous variables. Using multivariate logistic regression, we sought
to determine which factors were independently associated with 2 dependent variables, "see dental problems at least once a month"
and "openness to fluoride varnish." These outcome variables were of
interest as we anticipate planning targeted interventions. Covariates
in the model were chosen based on their hypothesized association with
the outcome variable. All statistical analysis was performed on
SPSS for Windows, Version 8.0 (SPSS, Chicago, IL).
Coding for Multivariate Analyses
The "see dental problems once a month" variable was coded as
one for those respondents who reported seeing caries on average at
least once a month. Those who saw caries less frequently were coded as
zero. Three main-effect, dichotomous variables were included: 
3 hours
of education in oral health topics in medical school and residency;
having 15% Medicaid patients, and 5% uninsured patients. These
cutoffs were derived from the median value for each of the respective
continuous variable. Two control variables
number of years in practice
and number of patients seen per weekwere also included in the model
as continuous variables.
"Openness to fluoride varnish" was coded as a one for those who agreed or strongly agreed that fluoride varnish should be part of well-child care in the pediatric office and as zero for those who were neutral or disagreed. Main-effect variables included in this model were 3 dichotomous variables: familiarity with fluoride varnish, strongly agreeing that pediatricians have a role in counseling and assessing for dental problems, seeing dental problems at least once a month; and 4 continuous variables: proportion of compensation from fee-for-service, fixed salary, and capitation (3 mutually exclusive categories), and the number of patients seen per hour.
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RESULTS |
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Top
Abstract
Methods
Results
Discussion
Conclusion
References
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Sample
Of 1600 surveys distributed, 40 were returned without a forwarding address and 174 were returned by physicians reporting that they were no longer in practice or did not include well-child care within the scope of their practices. Of the 1386 eligible participants, 854 returned completed surveys giving a response rate of 62%. Respondents were not significantly different from nonrespondents in years since graduation from medical school, board certification, or state of residence.
Demographic information on survey recipients and their practices is summarized in Table 1. Respondents had been in practice for a mean of 13.7 years. On average, respondents reported providing direct patient care for 39.6 hours per week and saw 114.2 patients per week. More than one third reported no instruction in dental health-related subjects in medical school and 42.3% reported no dental health-related instruction in their residency training.
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Knowledge and Familiarity With Preventive Therapies
The frequency of correct responses to the 4 knowledge questions is presented in Table 2. Nine percent of respondents correctly answered all 4 questions. Only 60.8% of respondents knew that a 3-month-old did not require fluoride supplementation, a question designed to assess awareness of 1995 recommendations for fluoride supplementation published by the AAP.12 The majority of respondents (79.5%) reported familiarity with dental sealants and approximately one half (50.9%) said that they were familiar enough that they could explain sealants to a patient. However, only 37.3% correctly answered a basic knowledge question on sealants. Twenty-two percent of respondents were familiar with fluoride varnish.
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Current Anticipatory Guidance and Assessment Practices and Opinion on the Role of the Pediatrician in Promoting Oral Health
Greater than 85% of respondents reported that they were likely or very likely to examine a child's teeth for cavities and to provide preventive counseling at well-child care visits for children under 5 years of age. Fewer respondents (72.4%) reported that they assessed fluoride intake to determine the need for supplementation. Only a small number of respondents (7.8%) reported that they were likely or very likely to inquire about the mother's dental health. More than 90% of respondents agreed that assessment for dental problems and preventive counseling should be a part of routine well-child care provided by the pediatrician, but only 14.6% of respondents were in agreement with referral to a dentist by 12 months of age, the current recommendation of the American Academy of Pediatric Dentistry (AAPD)13 (Table 3).
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Experience With Dental Problems and Perceived Barriers to Referral to Professional Dental Care
Forty-seven percent of respondents reported that they saw early childhood caries in their practices at least once a month. Cavities in older children were seen somewhat more frequently; approximately two thirds of the respondents reported that they saw cavities in school-aged children at least once a month. More than one half of respondents reported difficulty referring patients who were uninsured and who needed a sliding payment scale (55.1%) or who were uninsured with an emergent dental problem (50.9%). Fewer respondents reported difficulty referring patients in other categories (Table 4).
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Fluoride Varnish Application
Seventy-four percent of respondents would accept reimbursement to have fluoride varnish applied to patients within their practices at a mean of $20.45. An unusually high number of respondents (9%) left the reimbursement question blank. Only 21% agreed that application of fluoride varnish should be a part of well-child care provided by pediatricians. Sixteen percent of participants responded that no amount of reimbursement could induce them to apply fluoride varnish in their practice. Two primary themes arose in the accompanying open-ended question to explain this response: 1) participants reported insufficient time, space, or staff to perform this procedure, or 2) participants believed that this procedure should remain within the scope of professional dental practice.
Multivariate Analysis
In multivariate analysis, respondents with 15% Medicaid
patients were more likely to report seeing dental problems at least once a month, after adjustment for the number of patients seen per week
and the number of years in practice. There was a positive, but
statistically not significant, association of 3 or more hours of oral
health training in medical school and residency, and 5% or more
uninsured patients with seeing dental problems at least once a month
(Table 5).
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Openness to fluoride varnish was significantly associated with familiarity with fluoride varnish, seeing dental problems at least once a month, and strongly agreeing that pediatricians have a role in promoting oral health prevention. There was a significant negative association with proportion of salary from fee-for-service compensation. There was not a significant effect of proportion of capitated or salaried compensation or of the number of patients seen per hour (Table 6).
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DISCUSSION |
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Top
Abstract
Methods
Results
Discussion
Conclusion
References
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This survey indicates that pediatricians overwhelmingly believe that they have an important role in the promotion of oral health. The majority of pediatricians report that they are likely to include anticipatory guidance on oral health-related topics at well-child care visits and would be willing to accept reimbursement to provide fluoride varnish. They report encountering dental decay in their patients on a regular basis and have difficulty referring some subgroups of patients for patients for professional dental care. Lack of familiarity with oral health issues may make it difficult for pediatricians to promote oral health and suggests the need for more formalized training and standards for preventive oral health counseling and care.
Most pediatricians reported that they routinely assess a child's dental health and include anticipatory guidance on oral health in their well-child care visits. Relatively fewer pediatricians were likely to assess a child's fluoride intake to determine the need for supplementation, although this has traditionally been one aspect of oral health for which pediatricians have taken responsibility. There are several possibilities for this finding. Pediatricians may assume that there is not a need to make an assessment of fluoride intake if a child lives in a community with fluoridated water. Alternatively, some pediatricians may avoid addressing fluoride out of concern that current recommendations are no longer appropriate, given increasing exposure to fluoride from other sources.
Results of this survey also indicate that pediatricians encounter dental decay on a regular basis. This is not surprising given that >50% of American children have experienced dental decay and in some groups, such as Mexican-Americans, >45% of children 6 to 8 years of age have untreated dental caries.4 As expected, pediatricians who care for more patients at risk for dental decay reported seeing caries on a more frequent basis. Given the frequency with which pediatricians encounter dental problems in pediatric practice, additional oral health-related training in pediatric residency should be considered.
Although the majority of pediatricians encounter dental problems on a regular basis and are involved in the prevention of dental problems, this survey identified some barriers that may limit pediatricians' effectiveness in the promotion of oral health in their practices. First, pediatricians' knowledge of and familiarity with basic oral health-related issues were limited, particularly on topics where new information has emerged in the last decade. Other studies have documented similar limitations in dental knowledge among pediatricians.14-16 Few pediatricians were aware that caries are a transmissible infectious disease that the child can acquire from the mother, although this information has been disseminated in the dental literature for >10 years.11,17-20 Despite claiming familiarity with dental sealants, many respondents could not answer a basic question about how sealants are used. If pediatricians are to provide adequate counseling to their patients in the area of oral health, they need sufficient knowledge of current preventive practices in dentistry.
A second barrier to greater involvement in oral health by pediatricians is the perception that it is difficult to refer several subgroups of patients. Over one half of the respondents reported difficulty referring uninsured patients and more than one third reported difficulty referring Medicaid patients. Our findings are congruent with recent data that show that unmet dental care needs are the single most frequently reported health need.21 A recent survey of state Medicaid programs by the General Accounting Office found that, of 39 states providing information, 23 reported that fewer than half of the states' dentists saw any Medicaid patients in 1999.22 Problems accessing dental care are compounded in rural areas, where the availability of dental providers is more limited. If pediatricians are to play a greater role in promoting oral health in their practices, confidence in their ability to refer patients to professional dental care must be ensured.
Although pediatricians believe that they have an important role in promoting oral health, they seem to be ambivalent about assuming greater involvement. Most were willing to consider reimbursement for application of fluoride varnish, yet few agreed that application of fluoride varnish should be a part of well-child care provided by the pediatrician. The most frequent response to the opinion question on application of fluoride varnish as part of well-child care fell into the neutral category suggesting the possibility that respondents were not familiar enough with fluoride varnish to make a decision about adding it to their practices. In fact, only 22% reported familiarity with fluoride varnish. Although information on the purpose of fluoride varnish, the ease and length of time required for its application, and the inexpensive cost of the supplies was provided in the text of the survey, this may not have been sufficient to allow participants to commit for or against fluoride varnish application. This may also be why a relatively large number of respondents left the question about reimbursement for fluoride varnish blank.
Providers who saw dental problems regularly in their practices were more likely to agree with application of fluoride varnish in pediatric practice. It may be that pediatricians who work with patients at high risk for dental disease and who encounter difficulty accessing professional dental care are motivated to play a more active role in preventing cavities. Those who were familiar with fluoride varnish were more likely to be willing to apply fluoride varnish in practice. This finding demonstrates the potential for wider acceptance with greater familiarity with fluoride varnish. Openness to fluoride varnish was unrelated to proportion of compensation from fixed salary or capitation or from the number of patients seen per hour. We had hypothesized that busier pediatricians and those paid on fixed salary or capitation would be less likely to consider application of fluoride varnish. It is promising that these potential barriers seem less important than anticipated.
Most pediatricians did not agree with the recommendation of the AAPD that children be referred to the dentist by 1 year of age. Several possibilities may explain this finding. Pediatricians may not be knowledgeable of the AAPD recommendation and even if they are aware, they may not agree because this represents a change from that which they are accustomed. Some pediatricians may question whether dental assessment and preventive education for very young children require a visit to the dentist because the AAP has identified pediatricians as capable of providing "basic dental care for children under the age of 3."23 Pediatricians may be aware that insurance will not routinely cover preventive dental care in their state for children at this age, because the recommended age for referral varies by state. Other comments written on the survey suggested concern as to whether dentists were willing to care for very young children. This concern may be justified, given that, in a survey of pediatric dentists, only 46.6% practiced the AAPD policy of performing the first oral evaluation at 12 months of age or younger.12
There are several limitations to this study. As with any survey, there is the potential for responder bias. Although the response rate of 62% is consistent with other surveys of physicians, it is possible that the nonrespondents had different experiences and opinions regarding oral health in pediatric practice. Second, in an effort to provide a more desirable response, respondents may have overestimated the frequency with which they participate in oral health preventive activities in their practices. In addition, some questions asked for providers' perceptions and their responses may not represent patients' actual experiences. Finally, this survey was kept as short as possible, but this limited the use of open-ended questions and the ability to probe participants' responses for greater detail.
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CONCLUSION |
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Top
Abstract
Methods
Results
Discussion
Conclusion
References
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Access to dental care and unmet dental health needs are serious and underaddressed problems for poor and minority children in the United States. In promoting preventive oral health, pediatricians benefit all children and particularly the underserved. We know of 2 states, Washington and North Carolina, that have acknowledged, through the provision of reimbursement, that pediatricians have a unique opportunity at well-child care visits to provide caries prevention counseling and care to poor children.
Based on results of this survey, we believe it bodes well for expanding pediatrician involvement in oral health into other states. Specifically, we found that pediatricians overwhelmingly believe that they have an important role and are already involved in the providing anticipatory guidance on oral health issues. However, lack of up-to-date information and knowledge as well as the difficulty pediatricians perceive in referring some patients for professional dental care call into question the current level of effectiveness in promoting oral health of pediatricians. We offer several recommendations to begin the dialogue on expanding the role of pediatricians in preventive oral health:
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ACKNOWLEDGMENTS |
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Charlotte Lewis received funding from the Robert Wood Johnson Clinical Scholars Program to complete this study.
We thank Joann Elmore, Tom Koepsell, David Grembowski, Peter Milgrom, Wendy Mouradian, and the University of Washington Clinical Scholars for their advice and guidance; Michelle Perez for her assistance in conducting the survey; and Margaret Mitchell for her administrative support.
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FOOTNOTES |
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Dr Lewis was a Robert Wood Johnson Clinical Scholar while conducting this research. The opinions expressed here are not necessarily those of the Robert Wood Johnson Foundation.
Received for publication Feb 22, 2000; accepted Jul 27, 2000.
Reprint requests to (C.W.L.) Child Health Institute, University of Washington, Box 358853, Seattle, WA 98195. E-mail: cwlewis{at}u.washington.edu
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ABBREVIATIONS |
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EPSDT, Early Periodic Screening Diagnosis and Treatment; AMA, American Medical Association; AAP, American Academy of Pediatrics; AAPD, American Academy of Pediatric Dentistry.
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REFERENCES |
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Top
Abstract
Methods
Results
Discussion
Conclusion
References
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This article has been cited by other articles:
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  C. S. Massey, T. P. Raybould, J. Skelton, A. S. Wrightson, and T. A. Smith Advanced General Dentistry Program Directors' Attitudes and Behaviors Regarding Pediatric Dental Training for Residents J Dent Educ., March 1, 2008; 72(3): 344 - 351. [Abstract] [Full Text] [PDF]
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 M. Chu, L. E. Sweis, A. H. Guay, and R. J. Manski The dental care of U.S. children: Access, use and referrals by nondentist providers, 2003 J Am Dent Assoc, October 1, 2007; 138(10): 1324 - 1331. [Abstract] [Full Text] [PDF]
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 S. M. H. Nainar and S. Mohummed Role of Infant Feeding Practices on the Dental Health of Children Clinical Pediatrics, March 1, 2004; 43(2): 129 - 133. [PDF]
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 W. E. Mouradian Brighten children's smiles by taking proactive role in oral health AAP News, February 1, 2001; 18(2): 77 - 77. [Full Text] [PDF]
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