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: 1. Pediatricians will require adequate training in oral health in medical school, residency, and in continuing education courses. We recommend adding a module on oral health and dental care to the undergraduate medical school physical examination skills courses and an oral health rotation to pediatric residency curriculums. Having dental professionals provide such instruction would enhance acquisition of hands-on skills and could encourage future professional collaboration and cross-referrals. 2. Pediatricians will require current information and guidelines on preventive dental care. With the exception of Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, very little is available to guide pediatricians in the promotion of oral health in their practices. The American Academy of Pediatrics (AAP) publication, Guidelines for Health Supervision, provides cursory oral health advice limited to fluoride supplementation and dental referral. The scientific literature aimed at pediatricians is also limited. A recent Medline search of the 3 commonly read pediatric journals identified <20 articles with a primary focus on oral health published in the last 10 years. 3. Pediatricians must be ensured that all of their patients, Medicaid and uninsured included, can receive timely preventive and restorative dental care. Pediatricians can expand their involvement in oral health prevention, but they can never replace the care that dental professionals provide. Further dialogue with our dental colleagues and joint advocacy efforts by the AAP and American Academy of Pediatric Dentistry are needed to address the serious problem of disparities in access to dental care. 4. Pediatricians will require sufficient resources to successfully assume greater involvement in oral health-related activities. Time pressures and inadequate staffing will make it difficult for pediatricians to devote the attention to oral health that all children deserve.
