Preventive Dental Services in Primary Care

Millions of Americans currently lack access to dental care and oral health preventive services because of financial and/or geographic obstacles.^1,2 Although community water fluoridation has benefited many Americans during the past 50 years, difficulties in obtaining dental care is a persistent public health challenge.² Primary care providers (PCPs) can help improve health population-wide by educating patients in good dental hygiene and offering preventive oral health services to patients who would otherwise go without them.

The chief components of preventive dental care include daily brushing with fluoride toothpaste, flossing, routine dental check-ups and professional dental cleanings provided by a licensed dentist and staff, and use of dental sealants and topical fluoride. During the primary care appointment, a routine intraoral exam, including inspection of both hard and soft oral tissues for leukoplakia, gross decay, stained dental structures, and other pathologic changes, is essential. Primary care patients who use any form of tobacco should undergo inspection of the intraoral surfaces of the lips and assessment for adenopathy of the surrounding lymph nodes.

Counseling, including recommending routine preventive dental services (and, for some patients, allaying their fears of seeing a dentist^2,3), and positive reinforcement of good oral hygiene practices should be addressed during every primary care encounter. Identifying patients without access to professional dental care is important, as the PCP may be their only source of oral health education, including referrals to local dental clinics.

Application of topical fluoride is an important means of improving dental health, and a cost-effective procedure for both patients and providers4 (see “Fluoride Use,”^2,3,5-16). By following published guidelines for use of topical fluoride varnish, PCPs can reduce decay and mineralize enamel, thereby protecting the patient against enamel erosion.^6,11,17 This service can and should be offered in primary care offices to patients who lack access to routine dental care and are likely to benefit from this effective weapon against tooth decay.

BEA, AGE 3

Bea lives with her mother and four older brothers and sisters. She is enrolled in Medicaid, but her mother has been unable to locate dental services for any of her children. With every call to a dental office within a 30-minute commute from their home, Bea’s mother has been told, “We don’t accept Medicaid.”

Under her state’s Medicaid plan, Bea has been seen for her primary health care needs since she was a newborn. She was bottle-fed from birth; her mother reports she has stopped taking the bottle to bed within the past few months. While conducting her three-year well-child exam, you note gross decay (see Figure 1).

Dental Services for Children

Nationwide, Medicaid is required to provide coverage for dental services for enrolled children, as well as those who qualify for the CHIP (Children’s Health Insurance Program).²⁰ However, there is no mandate for privately owned dental practices to accept Medicaid payments.

Lack of dental care is the greatest unmet health care need in American children.²¹ In children without health insurance, access to dental care is most challenging, and those enrolled in Medicaid are the second least likely to receive services. As a result of these and other factors, one-third of US children ages 3 to 5 have dental caries in their primary teeth, and one in every four US children is estimated to have untreated decay^2,21-23 (see Figure 2). African-American and Hispanic children experience greater disparities in dental care than do those of other ethnicities.²¹

Dental decay is the most common chronic illness of childhood (five times as common as asthma), with higher incidence in low-income and minority preschool children.^1,24,25 Tooth decay affects growth patterns and nutrition, with associated pain and infection interfering with school attendance.