Tiny Tooth Teamwork

Dentists and pediatricians are teaming up to protect primary teeth, with increasing numbers of young children having fluoride varnishes painted on by a physician. It’s a paradigm shift for the dental industry.

More very young children are suffering from a rapid form of tooth decay. Yet they rarely see a dentist while there’s still time to spare them from costly, invasive treatment.

Those same kids, however, regularly see the pediatrician.

So in addition to vaccinating children and measuring their growth, physicians have joined the fight against early childhood caries. Most notably they are painting fluoride varnish onto teeth, which is reimbursed by medical insurers.

And dentists are collaborating with them, while also urging parents to find a dental home. “I believe that it’s critical that pediatric medical providers and pediatric dental providers team up in a way that together we can prevent or certainly slow down the effect of early childhood caries,” said Ray Stewart, DMD, MS, professor of pediatric dentistry at the University of California San Francisco’s School of Dentistry. “It’s absolutely necessary and absolutely essential if we’re to make any inroads at preventing the epidemic.”

Organized dentistry has endorsed the partnership and dental product suppliers are adapting, with supplier Henry Schein’s website describing the effort as a “paradigm shift.” But research shows that some dentists still have reservations. Physicians say that rather than step on the turf of their dental colleagues, they can help improve oral health and connect children to quality dental care.

For dental sales executives, it’s important to know why some oral health care for children is being provided outside the dental office. Reps can also help their clients understand the move toward greater cooperation between the two health professions that, in some cases, is starting during medical or dental school.

CAVITY PREVENTION

Dental caries is the most common chronic childhood disease, five times more common than asthma. Early childhood caries is particularly endemic among low-income and minority children, who have less access to dental care. Consequences range from pain and missed school to high costs to the health care system when toddlers must be put under general anesthesia for treatment.

Fluoride varnish is an inexpensive and noninvasive way to protect teeth. It re-mineralizes weakened tooth enamel and slows the progression of decay. It can be safely applied to an infant’s first teeth, which typically erupt around 6 months.


DENTISTS ARE TEACHING PHYSICIANS

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Dentists and physicians are finding innovative ways to collaborate. At University of California San Francisco, first-year medical students learn how to conduct an oral exam and apply fluoride varnish from UCSF dental students.

“Many medical and other health professional schools are currently providing training around oral health,” said Melinda Clark, MD, a board-certified pediatrician who specializes in oral health in Albany, New York “Since oral diseases continue to be the most common unmet health need across populations, we should be teaching more about oral health to ensure that all graduating physicians are able to provide anticipatory oral health guidance, identify oral disease early, and appropriately triage oral conditions.”

Ray Stewart, DMD, MS, professor of pediatric dentistry at UCSF, said another planned collaboration between physicians and dentists is establishing shared electronic medical records to ensure that services are not duplicated.

In Ohio, a $4.6 million grant from the National Institutes of Health to Case Western Reserve University School of Dental Medicine will train about 90 pediatricians to apply fluoride to the teeth of nearly 3,700 low-income children during well-child visits. They will also discuss the importance of baby teeth, problems associated with untreated cavities, and give children a “prescription” to see a dentist.

According to the school’s website, by the end of the project, researchers hope “to pinpoint messages that most effectively sway parents and caregivers to take their children to the dentist.”


“Fluoride varnish is a very effective way to apply fluoride to teeth,” said Jeff Dalin, DDS, who practices in St. Louis and co-founded Give Kids a Smile, which provides free dental care to about 300,000 children each year at volunteer-run events where fluoride varnish is applied. “It delivers a good amount of fluoride at each application.”

Research has shown that the varnish effectively prevents decay when applied three to four times by age 2. An analysis by Pew Charitable Trusts found that fluoride varnish can reduce decay rates by one-third and lead to “significant cost savings in restorative dental care and associated hospital costs.”

It’s also inexpensive and relatively easy to apply. A .25 mL dose of varnish costs $1 or $2.

WHY PEDIATRICIANS GOT INVOLVED

Young children, particularly those in low-income families, see primary care physicians earlier and far more often than they see dentists, with 10 well-child visits typically scheduled by age 2.

A 2013 report by the American Academy of Pediatric Dentistry (AAPD) said early dental visits are strongly recommended yet rarely made. Additionally, not enough dentists treat very young children, especially those covered by Medicaid, the government program for low-income families.

“Pediatric primary care providers often treat the consequences of tooth decay and we are responsible for the overall health of children,” said Melinda Clark, MD, a board certified pediatrician who specializes in oral health in Albany, New York. “Very young children, especially ages 0 to 3, visit the pediatrician far more times than they ever see a dentist, such that physician visits outnumber visits to dentists at 250 to 1 among 1-year-olds.”

Initially, the move for pediatricians to apply the varnish was aimed at low-income children who face an array of barriers to seeing the dentist, which may include a lack of providers, lask of transportation or limited English proficiency.

In the late 1990s, state Medicaid programs began reimbursing primary-care physicians for the service.

In 2014, the U.S. Preventive Services Task Force, an independent panel of primary care experts, issued a recommendation that medical doctors apply fluoride varnish to “all infants and children” starting at the age of eruption of the first tooth.

Clark, who is also an associate professor of pediatrics at Albany Medical Center, said pediatricians are also well positioned to provide early risk assessment, instructions on infant oral hygiene and proper oral habits, and a “timely referral” to a dental home.

“The earlier we begin prevention strategies, the more successful we will be in preventing dental disease, so we must begin during infancy or even prenatally,” she said.

By law, the task force’s backing required that all health plans reimburse physicians for the service. In 2015, the American Academy of Pediatrics (AAP) added fluoride varnish to its Periodicity Schedule of services children should receive at appointments such as height and weight measurements and autism screenings. A medical Current Procedural Terminology (CPT) code was also adopted that year for application of fluoride varnish by a physician or other health professional.

To help physicians, the AAP website provides links to dental supply companies where pediatricians can connect with sales reps and order fluoride varnish.1 The website also offers downloads of post-varnish instructions for parents in eight languages.2

But medicine’s foray into fluoride varnish does not diminish the need for children to also see a dentist regularly, medical providers say.

Clark noted that medical and dental providers all agree that children should visit a dentist by 12 months of age. That recommendation is shared by the AAPD, the AAP and the American Dental Association (ADA).

“It is important that both pediatric primary care providers and dental health professionals consistently reinforce this message,” Clark said. “Many families encounter barriers to accessing dental care, including financial, insurance coverage, transportation, and competing medical needs. I encourage pediatric primary care providers to form collaborative relationships with their local dental colleagues to help their patients find dental homes.”

The AAPD has reported a need for more pediatric dentists as well as general dentists willing to treat very young patients. Clark said that her profession can help encourage general dentists to see infants and toddlers.

“Many general dentists are not comfortable caring for young children, so even healthy young children are allocated to the pediatric dentist chair,” she said. “Dental health professionals can teach pediatricians much about oral health and pediatricians can help general dentists feel more comfortable with the behavioral management of young children.”

RESPONSE FROM DENTISTRY

Organized dentistry has long voiced support for physicians to delve into oral health, but has also expressed some cautions. Despite that endorsement, some dentists see physician involvement as a last resort rather than something that should be routine.

A 2009 article published in the Journal of Public Health Dentistry included a survey of dental practitioners’ views on pediatrician application of fluoride varnish. Only 51% supported the practice.

The ADA’s House of Delegates in 2004 passed policy stating that physicians and their properly supervised and trained designees “be allowed to provide preventive dental services to infants and young children.”

Two years later, an American Academy of Pediatric Dentistry document said that “fluoride varnish interventions are not a substitute for the establishment of a dental home” and should only be provided after a comprehensive dental exam.


THE VARNISH BRIGADE

Pediatricians and nursing assistants aren’t the only non-dental practitioners learning to apply fluoride varnish. In California, a 2010 law, AB 667, allows anyone working in a public health or school setting to apply the topical fluoride, with a prescription and protocol set by a dentist or physician. That means dental assistants, teachers, parents and community health workers can apply varnish. The legislation was sponsored by the California Dental Association.


It says if Medicaid or other insurers do reimburse physicians, the following should apply: Adequate training for physicians with live or video demonstration by a dentist and thorough understanding by physicians of the effectiveness and limitations of fluoride varnish “as they will be held to the same standard of care as dentists.”

Stewart called those guidelines “fair cautions” and said that dentists can help physicians by offering training, and physicians can stress the importance of a dental visit to parents.

“I believe most pediatricians are diligent in emphasizing to parents that we’re putting fluoride varnish on as a means of preventing caries, but this is not a dental exam. You should definitely get your child in to see a dentist,” Stewart said.

Dalin said for pediatricians who do apply varnish, proper training is important.

“This is something that should not be taken lightly,” he said. “We want both children and adults to get the best quality dental care. Good dental care along with good home oral health habits can lead to very healthy oral conditions. Our goal is always a cavity-free, restoration-free mouth for everyone.”

Dalin said he thinks pediatricians should provide care only when children have no access to a dentist.

“I feel that dental care should be delivered at a dental office,” Dalin said. “Parents should find a dental home for themselves and their children and have all of their dental needs met there.”

According to Pew, Medicaid pays between $15 and $30 for application of fluoride varnish by medical providers. Some private medical plans pay $30 to $50. Stewart said in his practice, private dental insurers pay about $55 for an application.

Stewart said for children who are seeing both the dentist and pediatrician, it’s important to have good communication with parents and between providers.

“I think pediatricians should be saying, ‘Did your child have fluoride applied at the dental office?’ Great, then we don’t need to do it here,’” Stewart said.

For dental reps, it’s important to recognize that some basic dental services are expanding to primary care settings but that the ultimate goal is not to replace what dentists do, but find ways to get more young patients in to see them.

 
Featured photo by IMGORTHAND/E+/THINKSTOCK

REFERENCES

  1. Dental Supply Companies Contact Information. Available at: www2.aap.org/commpeds/dochs/oralhealth/docs/fluoride-varnish-manufacturers.pdf. Accessed Feb. 6, 2017.
  2. Directions for Your Child’s Care After Treatment. Available at: www2.aap.org/commpeds/dochs/oralhealth/docs/varnish-instructions-ALL.pdf. Accessed Feb. 6, 2017.

From MENTOR. March 2017;8(3):16-18.

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