Colleen E. Huebner, Ph.D., M.P.H., is Director of the Graduate Program in Maternal and Child Health and Associate Professor, Department of Health Services, at the University of Washington. Peter Milgrom, D.D.S., is Professor of Dental Public Health Sciences and Director of the Northwest Center to Reduce Oral Health Disparities at the University of Washington.
Recent U.S. health surveys have documented a decline in the oral health of young children. According to the U.S. Department of Health and Human Services, between the periods 1988-1994 and 1999-2004, the prevalence of tooth decay in the primary teeth of children ages 2 to 4 years increased from 18 to 23%. The prevalence is higher among low-income children. The Centers for Disease Control and Prevention (CDC) reported that 54% of children ages 2 to 5 years living below the federal poverty level have caries in their primary teeth.
One low-cost, highly effective, and readily available strategy to prevent caries is brushing twice a day with fluoridated toothpaste. The use of fluoridated toothpaste, widely advertised for its therapeutic effects starting in the 1960s, was likely responsible for the dramatic drop in tooth decay in permanent teeth in the United States.
The risks and benefits of using fluoridated toothpaste to prevent caries in primary teeth is a topic of current debate. The primary risk is that too much fluoride can result in fluorosis in the permanent incisors. Typically, this is a minor cosmetic concern and nothing compared to the destruction of the teeth by rampant decay. In weighing the risks and benefits, the American Academy of Pediatric Dentistry (AAPD) advises that fluoridated toothpaste be used in children under 2 years of age when a child has risk factors such as a cariogenic diet, poor oral health of family members, or lack of community water fluoridation. Parents and early childhood specialists report this is confusing advice, because the U.S. Food and Drug Administration (FDA) requires labels on toothpaste warning against its use with children under 2.
Health disparities researchers at the University of Washington are carrying out a novel project using social networking tools, such as Facebook and Twitter, to alert child advocates to the confusing and contradictory advice about the appropriateness of fluoridated toothpaste for children at risk for early childhood caries (ECC). Short messages, pointing the reader to an editorial in The Journal of the American Dental Association (JADA), are designed to spread the word about the problem in a systematic way. They point to the ethical responsibility of dental educators and members of the research community to create new knowledge and to advocate for its dissemination to benefit the public at large.
In a guest editorial we published in JADA, "Fluoridated Toothpaste For ECC: Failure to Meet The Needs of Our Young," we argued that rigorous randomized trials of the effects of fluoridated toothpaste on the young deciduous dentition were lacking and urgently needed in order to inform the profession and the public. Concerns about fluorosis have trumped a serious analysis of risks and benefits in the face of an inevitable decline in the nation's oral health. All parents, including low-income and minority parents whose children bear the main share of tooth decay, are left with little guidance. Unlike community water fluoridation, a universal preventive measure opposed by many in the United States, use of fluoridated toothpaste is an individual choice. Parents should know of its benefits so they can make a reasoned choice on behalf of their children.
The lack of response to our editorial is alarming. We document gaps in knowledge, and more importantly the failure to move scientific findings into meaningful clinical trials, in "A Critical Examination of the Science and Technology of Prevention of Tooth Decay in Young Children Since the Surgeon General's Report on Oral Health," appearing in a 2009 issue of Academic Pediatrics. We identify strategies that, if applied widely, might reduce the enormous disparities that exist in access to oral health for those least fortunate.
The American Academy of Pediatrics (AAP) and the AAPD recommend that a child has his or her first visit to the dentist at 12 months or within 6 months after the eruption of the first tooth. These recommendations grew from increasing evidence that, to succeed, primary prevention must be instituted within the first 24 months of life. In practice, the country is far from implementing this approach or achieving such savings. In North Carolina, where early visits have been a priority for some time, only 23 of 53,591 eligible children on Medicaid had a dental visit consistent with the guidelines. The national data are similar.
Dental educators have a central role in changing these statistics and achieving the goals set by AAP and AAPD for primary preventive dental care beginning in infancy. Curricula should include anticipatory guidance for parents of young children, including supervised practice in how to instruct parents in home oral hygiene with the use of fluoridated toothpaste, regular application of fluoride varnish, use of topical antiseptics, and counseling techniques such as motivational interviewing to change attitudes and move parents to take action. These competencies should not be limited to pediatric residency programs. In reality, general dentists in community-based practices are the best placed to care for the routine dental needs of young children. There are more general dentists than pediatric specialists, routine preventive measures do not require a specialist's expertise, and with easier access to community dentists, it may be easier for parents to return for subsequent care, thus establishing a dental home for their children.
The University of Washington social networking research will track how social networks respond to the call for action and whether there is any response within industry, government, or the dental profession to address the problem. Visit our Facebook page for more information.