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December 7, 2021

Reducing Inequities in Early Childhood Dental Caries in Primary Health Care Settings

Author Affiliations
  • 1Department of Dental Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 2Department of Pediatric Dentistry, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 3Division of Pediatric and Public Health, Adams School of Dentistry, University of North Carolina at Chapel Hill
  • 4Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill
  • 5Department of Cariology, Restorative Sciences and Endodontics, University of Michigan School of Dentistry, Ann Arbor
JAMA Health Forum. 2021;2(12):e214115. doi:10.1001/jamahealthforum.2021.4115

Dental caries is one of the most prevalent chronic noncommunicable diseases among children in the US and the world1 and one of the most common unmet health care needs of underserved children.2 This costly and burdensome disease can result in severe pain, failure to thrive, and poor school performance, which have consequences for a child’s short- and long-term future. Dental caries can start in early childhood and progress throughout the life course, despite being preventable. Many of the behaviors that cause dental caries are established early in life, which makes early childhood a critical period to establish effective healthy practices and start preventive interventions. To address these challenges, primary care clinicians have been called on to assess the oral health of their patients; provide anticipatory guidance and counseling about oral hygiene, fluoride exposures, and diet; assist with referrals; and apply fluoride varnish.

In an updated Recommendation Statement in this issue of JAMA,3 the US Preventive Services Task Force (USPSTF), supported by an updated evidence review,4,5 issues recommendations similar to those in its 2014 Recommendation Statement on screening and interventions to prevent dental caries in children younger than 5 years,6 including the application of fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption (B recommendation).3 Fluoride varnish is one of the simplest, safest, and most effective professionally delivered strategies available to prevent caries,7 and its use is considered part of care in pediatric primary care. Yet interprofessional efforts to curb the prevalence and severity of this persistent childhood disease have not been successful at decreasing disparities and inequities in dental caries prevalence and access to care experienced by minority, poor, and underserved children in the US.

In fact, despite previous recommendations, existing policies, and reimbursement, fluoride varnish use in medical settings for all young children has remained underutilized or utilized in a subjective manner.8 Furthermore, current evidence suggests that application of fluoride varnish in a clinic setting is more likely to be cost-effective in populations with high caries risk, which indicates a need to target groups with higher risk.9 Therefore, actions must be taken so that these USPSTF recommendations can be implemented more effectively than in the past, with strategies to reduce the persistent large disparities and inequities in caries rates and access to care. The USPSTF recommendations highlight the higher prevalence and severity of dental caries among low-income and certain racial and ethnic (eg, Black and Mexican American) populations.3 Specifically, dental caries “prevalence is higher in Mexican American children (33%) and non-Hispanic Black children (28%) than in non-Hispanic White children (18%).”3 For these USPSTF recommendations to decrease—rather than widen—disparities in child dental caries, innovation in how to implement and tailor preventive dental care is needed at both the individual and population levels, resulting in an equitable delivery of preventive strategies by primary care clinicians.

Lessons on equitable access to preventive child health services and the health care system have been gained through the response to the COVID-19 pandemic. The primary unmet child health care need during the COVID-19 pandemic was not medical care but dental care.10 Dental offices closed and school-based dental prevention programs were suspended, with many school-based dental programs not re-engaging until recently in many parts of the country.11,12 During this time of greater need for oral health promotion during the COVID-19 pandemic—when families have experienced numerous challenges accessing dental services from dentists and school-based programs—the delivery of preventive dental services by primary care clinicians, endorsed by these USPSTF recommendations, has been even more critical. However, there has also been a reduction in the administration of other preventive services to children, like vaccinations. Thus, as efforts are put into place to increase access to all preventive services in primary health care settings, the need for integration between medical and dental health care systems to deliver preventive services to children to effectively prevent dental caries is more critical than ever.

In dentistry, as in medicine, persistent and growing disparities and health care inequities13—together with escalating health care costs and resource constraints—have emphasized the need for targeted, risk-based preventive and therapeutic approaches when obtaining high value in return for health care interventions.14 However, although several caries risk assessment tools exist, none have been validated for use in children in the US in the primary care practice settings. The 2021 USPSTF recommendations conclude that there is insufficient evidence to make a recommendation for or against routine screening examinations for dental caries performed by primary care clinicians for children younger than 5 years (I statement).3 This suggests that a call to action is imperative. Future efforts should focus on improving and standardizing methods and reporting of screening and prediction modeling in caries research, conducting implementation research to better incorporate validated models in practice, with the inclusion of more sophisticated data mining and analytical methods.15 A current research project funded by the National Institutes of Health is developing and validating a short (10 items) risk assessment/screening tool to identify young children at risk of dental caries in primary health care settings.15 Such a tool would allow nondental professionals in medical and school-based settings to become more actively involved in preventing dental caries and referring children with high caries risk. Once a tool is developed, challenges remain around its dissemination and implementation and around assessing the economic effects of establishing a risk-based approach to caries screening and prevention. In addition, high-risk individuals require a periodicity of preventive services that may be difficult to achieve in a single setting; thus, working in an integrated manner might be the only way to address the access to care needed for efficacy of interventions delivered.9

Two strategies can be emphasized now to promote the equitable implementation of evidence-based preventive oral health services. First, promote appropriate age–dependent use of fluoride toothpaste in the home. Use of fluoride toothpaste is considered one of the most important strategies in preventing dental caries throughout the life span.16 Ensuring that families start the habit of fluoride toothpaste use in children as soon as the first tooth erupts is of critical importance.17 Second, promote support of healthy dietary habits, reducing the intake of free sugars, which can positively affect health outcomes associated with dental caries and general health conditions, such as obesity and diabetes.18 The connections made by primary care clinicians between oral and overall health, and recommendations around use of fluoride toothpaste and a healthy diet, can be performed equitably during the pandemic via telehealth. Moreover, the promotion of child oral health by primary care clinicians reinforces the daily health promotion behaviors for children that are being endorsed by the dental community, strengthening the consistent messages through interdisciplinary anticipatory guidance.

These USPSTF recommendations contribute to the necessary interdisciplinary approaches to promote the oral health of children and advance progress toward the Healthy People 2030 goal of reducing the proportion of children with active and untreated dental caries. Additionally, these recommendations are a positive challenge for the child health community. They are a call for the research community to address the persistent disparities in dental caries in children and provide better tools to implement the recommendations in a manner that reduces inequities. Answering these research questions will be essential to improve the current and future oral health of young children and to implement the known evidence-based interventions for prevention of dental caries and its negative consequences in the most vulnerable children.

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Article Information

Published: December 7, 2021. doi:10.1001/jamahealthforum.2021.4115

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Burgette JM et al. JAMA Health Forum.

Corresponding Author: Jacqueline M. Burgette, DMD, PhD, University of Pittsburgh School of Dental Medicine, University of Pittsburgh, 3501 Terrace St, Pittsburgh, PA 15261 (jacqueline@pitt.edu).

Conflict of Interest Disclosures: Dr Divaris reported receiving grants from the National Institute of Dental and Craniofacial Research and serving as a consultant for Colgate-Palmolive Company. Dr Fontana reported receiving grants from the National Institute of Dental and Craniofacial Research and receiving grants from, and serving as a consultant for, Colgate, Proctor & Gamble, Delta Dental Foundation, and CareQuest. No other disclosures were reported.

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